Kirklin Clinic Head & Neck Cancer Support Group, Birmingham, AL
distributed by American Cancer Society
Pat Sanders, Editor
Yeast - Research and Reflection by Pat Sanders
It is not uncommon for us to have some amount of yeast, a fungus, in the digestive tract and it may not ever give us a cause for concern. It is when we have an overgrowth of yeast in comparison to the good bacteria that causes problems. Not a very technical explanation, but these do not “fight” each other. They live together but an overgrowth of yeast means it is taking up more room than it should and you don’t have room for the good bacteria you need.
Why do we, who have had throat cancer, talk about this yeast so much and why do so many TEP users especially, though not exclusively, take medication for it? Let’s have a look at who gets it, why some never notice, and what are some of the steps we can take to ease a yeast problem. Maybe we can help with ideas to keep it under control.
Who has yeast that multiplies too much? Many of us do at one time or another. The list of those who are at risk starts with babies, who sometimes get what is called thrush and have white patches in the mouth. A friend of mine had IMRT radiation treatment for his cancer and one of the worst everyday problems for him was thrush, an overgrowth of oral yeast. This is actually a fungal infection, which is temporary but requires treatment. In my friend’s case, it kept coming back with white patches, difficulty swallowing, and no appetite, until the treatments were over. Adults who wear dentures have some yeast and most likely will never know it. It may never bother them. People with immune system deficiencies or metabolic disorders, such as uncontrolled diabetes, RA, HIV, MS, or Crohn’s disease, are more susceptible to having yeast problems.
We have known for years that taking antibiotics can leave us with a yeast infection. Any immune suppressing drug may do the same. Other cancer treatments, such as chemo, can cause this side or after effect. It takes a change of this type in the body that favors the growth of yeast to make it noticeable. Some people have a burning sensation in the mouth and throat that might be caused by this fungus. Yeast can cause bad breath and bad taste, a raw and burning mouth, thickened saliva and, of course, it can colonize on a prosthesis even before the yeast overgrowth is bad enough to have these more obvious symptoms.
We, who wear prostheses, may have a problem with talking or leakage caused by the colonization of these yeast.. We know that the esophageal end of the prosthesis is exposed to whatever we swallow and if the yeast is in our saliva, the prosthesis is like an island in the stream where the yeast can get a foothold and colonize. Have you ever looked carefully at a prosthesis that has been removed? I thought it was important enough to write an article (March 2001 HeadLines) about how we need to examine the old prosthesis and I suggested you rinse the old one under the tap and look at it, preferably in the sunlight or very good lighting. I have even soaked one in peroxide first to remove stains (coffee can leave it looking brown), If you see little areas around the flange that look like yellow powder that has hardened, that is yeast. You may have to use a magnifying glass. Check around the edge of the flange that holds the prosthesis in the esophagus and see if it is smooth. Sometimes the edge will feel rough and if you scrape away the roughness, the edge is no longer perfectly round. This is part of what yeast does. You can’t scrub or brush this away after a deposit is there. This may look ugly but the yeast you see on the flange is not the part that will make that prosthesis leak through the middle. That will be deposits around the area on a “Low Pressure” where the valve (flap) of the prosthesis closes. Using a brush several times a day and running it barely through the valve opening twisting it slightly as you go may clean the yeast off of that area before it hardens and is like a barnacle on a ship’s hull. There are new yeast resistant prostheses that may help your problem with yeast deposits on your prosthesis but it wouldn’t hurt to try to reduce the amount that is knocking at the door of your low pressure one!
What can we do about it. In addition to the antifungal medications, any underlying conditions or causes need to be brought under control. If you are undergoing chemo, or on prolonged antibiotics, it is likely that you will be better after treatment is concluded. However, it is also likely that it will take medication to help get you back to the point where your natural body chemistry and defenses will take care of leveling off the yeast numbers as opposed to the good bacteria who want to live there, too. After taking antibiotics, a short course of treatment for yeast may be all you will need. One of the medications is one pill. That is not one-a-day; it is one pill, … of Diflucan. That might be all it takes for some to get back to normal. For people who have really bad cases, some doctors give it for a longer period, 3 weeks or so, but it can have side effects and many doctors prefer not to use it at all if Nystatin to swish or Mycelex troches will work. However, from a patient’s point of view, if one Diflucan pill after a round of antibiotics will stop a vaginal yeast infection in its tracks, then chances are it will work for oral yeast in a mild case. If it doesn’t, some doctors are prescribing it in other quantities. Once you control the immediate problem, there may be some ways to avoid prolonging these fungus infections or getting another.
Nutrition is always very important. Eat foods with fiber and plenty of vegetables. Stay away from excess sugar and fat. Getting and keeping your body in shape puts you a step ahead. If you are diabetic, control it so the high sugar in the saliva isn’t feeding the yeast. Replace or repair your dentures if they are leaving raw places.
This is how you start. If you are able to improve your health or immune system by taking better care of yourself, then you are not as likely to have an overgrowth of yeast and add to your problems. Now, don’t laugh, but people who exercise tend to have better body functions and are, in general, healthier. Drink your full quota of water. I have heard good comments made about deep breathing. None of these suggestions will hurt you. If they don’t help the yeast situation, they will help you to feel better and let your body naturally fight for you to be in good health.
Is there something you can add to your diet to help achieve the balance you need to keep the yeast from overpopulating? Yes. Acidophilus. Yogurt with live culture is the best known of the foods that will add this. It is a food that will help to add the good bacteria we have been talking about. You can take powdered acidophilus in a capsule but it is a tasteless powder so you can open a capsule, add it to food or liquid, even your daily yogurt and get some more goodies in your gut!
Daily oral cleaning habits can be improved and here are some suggestions that may help. Your mouth may be sensitive so you need a soft toothbrush and you might want a Water Pic to rinse your mouth often, using the most gentle setting. If you are doing regular cleaning, you can use a slightly stronger water pulse but don’t turn it on full blast because that could damage your gums. This is a very good way to clean in between your teeth and to rinse thoroughly before and/or after brushing. I also suggest you consider something like a Sonicare. It is gentle and effective for cleaning.
It might be a good idea to spend a few minutes getting your mouth very clean after you have eaten for the last time at night. That way, you are spending the longest period of the 24 hours each day with no food in your mouth and nothing to encourage the yeast.
Yeast will stay on fabric and then reactivate so it might pay to wash your stoma covers and washcloths in hot water. If yeast forms and grows in the mouth, it is likely that your tooth brush could have yeast on it along with other germs, so how do you make sure your toothbrush is clean. Putting yeast back in your mouth or through your prosthesis with those brushes and cleaning tools doesn’t seem like a very good idea to me so what will kill the yeast on these?
You can kill some germs by soaking in peroxide, mouthwash, or a combination. But, it appears those things don’t kill yeast. What does? Hot water over 122 degrees. Hot water heaters set at 125 would never get it to the faucet at near what you would need.. Rinsing equipment under the hot water faucet is not enough. Setting the temperature very high is a bit dangerous and why heat 40 or 50 gallons when you don’t need much? The dishwasher has extra heat so things you put in there would get the kind of heat you want. However, how about using a Pyrex measuring cup with a handle and putting in it all of the items you want to clean with hot water. Heat some water in the microwave or in a teakettle and pour the very hot (not boiling…that is 212F) water over all the equipment you use to clean your stoma and prosthesis. The small brushes, the tweezers. Let them cool in the water and then put them back to use the next time.
I have wondered about drinking hot drinks like coffee or tea Since the serving temp of coffee or tea is usually 155 to 165, there is a possibility that a few yeast might succumb as you sip the hot drink but if it doesn’t help kill yeast, it at least will make you feel better!
I hope you have learned a little bit about yeast and will understand that sometimes medicine alone isn’t enough. You have a responsibility for self-care. These suggestions are not cures but can let the medicine work better and can possibly stop the next overgrowth before it starts.
Some of the sites researched on Yeast
The following site, which provides information for people with HIV/AIDS, has a list of medications for people who are dealing with more severe cases. I am copying the part about the medication because the differences are explained more clearly than most of the medical or pharmaceutical sites. This provides some education for you to be able to talk with your SLP or doctor about what is being prescribed for you.
Topical treatment (active only on the area where applied) is generally the first choice for oral candidiasis and usually works for mild-to-moderate cases. Topical treatments for oral candidiasis include lozenges (also called troches) and mouth rinses.
One or two lozenges are taken for oral symptoms three to five times a day. They should be sucked slowly and not chewed or swallowed whole. Common brands are clotrimazole (Mycelex) and nystatin (Mycostatin).
Mouth rinses are generally less effective than lozenges since they are only in contact with the mouth for a short time. However, they may be the best choice for someone who has a very sore and dry mouth. Rinses are taken in between meals, in a measured amount and are held in the mouth for as long as possible. They should be swilled around in the mouth, then swallowed. They are used at least four times a day and should be continued for a few days after the symptoms have gone (generally two weeks). The most widely used rinse is nystatin (Mycostatin).
Systemic treatment (treatments that work throughout the body) are used for recurring candidiasis or outbreaks that do not clear up with topical treatment. They are also used for esophageal candidiasis.
Three anti-fungal drugs are approved for use in treating oral and esophageal candidiasis. They include ketoconazole (Nizoral), fluconazole (Diflucan) and itraconazole (Sporanox). Generally, doctors will start out with less aggressive therapies (like ketoconazole or itraconazole) and save the more potent fluconazole for later use, if necessary. If candidiasis does not improve with these drugs (i.e. becomes “azole” resistant), another drug, called amphotericin B (Fungizone) is often tried.
The dose of fluconazole is 200mg once a day for oral and esophageal candidiasis. Treatment typically lasts two weeks for oral candidiasis and three weeks for esophageal infection (or two weeks after symptoms clear up, whichever is longer).
Itraconazole is usually taken at a dose of 100mg once a day for oral candidiasis for one-to-two weeks and 200mg once a day for esophageal candidiasis for two to three weeks. It should also be taken with food. Itraconazole oral solution gives higher levels of the drug in the blood than the capsule and has been shown to be more effective. There is a greater potential for interactions between itraconazole and many anti-HIV therapies. For more information on drug interactions, call Project Inform’s Infoline and ask for Drug Interactions.
Ketoconazole (Nizoral) is usually taken at a dose of 200mg once a day for oral candidiasis for one-to-two weeks and 400mg once a day for esophageal candidiasis for two-to-three weeks. It should be taken with food. It may not be well absorbed in people with gut problems or who cannot eat very much. Taking it with an acidic drink (such as cola) may help.
Amphotericin B (Fungizone) is administered by an oral solution (100mg a day four times daily) or through intravenous injection (generally .5mg/kg a day) for two to three weeks. Newer liposomal versions of the drug, such as amphotericin B lipid complex (Abelcet), is administered by intravenous injection at a rate of 5mg/kg a day for two to three weeks.
Email Q & A from the Past
The following Q & A came from a member of the Larynx-C email list in January, 1998.
The question is a familiar one even today and the answer was provided by Dr. Carla Gress, who, at that time, was working with Dr. Mark Singer and today is the Director of the IAL Voice Institute.
My father is recovering from laryngectomy surgery. The area between his chin and stoma is very swollen and hard as a rock, which seems to be very uncomfortable and he feels as if he's carrying something heavy under his chin. Is this kind of extreme swelling and hardening of the skin normal and what would you suggest to reduce the swelling? The wound is still a little raw, and he was told that it would take a while to heal entirely because of previous radiation to that area. Since the stoma is still not healed entirely he keeps opening it a little bit each time he touches it to put the tube in and out or to speak.
It is best for your father to check with his physician about the swelling under the chin, especially if it is draining. It may just be part of the healing process, however, and nothing to be alarmed about.
If closing the stoma with a finger causes the tissue to bleed or is very tender, your father should definitely wait awhile to use the prosthesis and instead rely upon the Servox. How is he keeping the stoma clean? We typically tell laryngectomees to put a little hydrogen peroxide on a gauze pad and press this against the skin around the rim of the stoma (never IN the stoma!) to loosen any crusts, then gently remove them with a tweezer. When wiping secretions, it should be done gently with a soft handkerchief or facial tissue. It does take some time for the stoma to "mature", particularly if there has been a high dose of radiation to the area. Sometimes it is helpful to use a skin cream on the area around the stoma to promote healing. We find that some of the over-the-counter creams work very well, particularly those with zinc. There are lots of expensive cosmetic creams that contain zinc, but a good old standby is Desitin ointment. You can find this in the baby section - its main use is for diaper rash. Hey, don't laugh, it works! But again, it is hard to know exactly what may be wrong without seeing the skin. If this continues to be a problem he should definitely see his physician to make sure it is not an infection or something serious like cellulitis.
The tube that is worn in the stoma is referred to as a tracheostoma vent or laryngectomy tube. It helps to establish a round stoma of adequate size for breathing. Some folks don't need to wear them, others wear them only until things heal, some wear them only at night, others need to wear them religiously with removal only for cleaning. He should definitely keep this in until the physician tells him it is okay to stop wearing it. In some laryngectomees, the stoma will shrink down and make it difficult to breathe, and a small stoma definitely makes it harder to see and change the voice prosthesis.
Carla Gress, ScD, CCC-SLP