Dysphagia or difficulty swallowing is one of the most common complications resulting from laryngectomy.  In general, we tend to think of chewing and swallowing as automatic. Most people do not realize what a complex activity consuming a meal can actually be, until there is some sort of problem.

 Some laryngectomees have difficulty with one or more stages of the feeding process. Swallowing problems can be acute or chronic. In general, laryngectomees who have had to undergo surgeries that extend to the oral cavity have greater difficulty swallowing than individuals who did not require surgeries that extended to the oral cavity. Moreover, laryngectomees who have had to undergo radiation therapy and/or chemotherapy tend to have more difficulty than laryngectomees who did not have to undergo these. However, laryngectomees whose surgeries extended to the pharynx and/or esophagus do not seem to have significantly more problems swallowing than any other laryngectomee, even though their surgeries may have required extensive reconstruction including grafts.

 Most professionals consider swallowing to be a four step process:

 Step one is the preparatory stage.  This stage involves taking food from the spoon and/or sipping liquids from a container. If in addition to having had a laryngectomy, a person has also had to have parts of the oral cavity removed or nerves have been damaged during surgery it may be difficult to take food from a spoon or sip liquids from a cup or straw.

 Step two is the oral stage.  This stage involves chewing food and/or holding foods and liquids in the mouth prior to initiating a swallow. If certain parts of the mouth have been surgically removed (tongue, palate, jaw, etc,) or the nerves that control parts of the oral cavity have been damaged, it can be very difficult to chew and/or move food and liquids from the front of the mouth to the back of the throat.

 Many of the side effects of radiation can make eating and drinking a difficult and/or unpleasant activity. Radiation therapy can result in dental problems of tooth loss, radiation caries, and osteoradionecrosis. These problems can make it difficult and/or painful to chew. Radiation therapy can temporarily damage the taste buds. When food has no taste or does not taste the way it should, it is often difficult to motivate oneself to eat and drink. Radiation therapy can also cause permanent damage to the salivary glands which results in xerostomia.  In addition to keeping the mouth, teeth, and gums clean and lubricated, saliva plays a very important part in the swallowing process.  Saliva helps convert solid foods into a cohesive ball of food bolus and helps lubricate the food so it can be more easily transferred from the front of the mouth to the back of the mouth and eventually down the esophagus.

 Radiation therapy can also cause jaw pain and stiffness, i.e. trismus and/or tempromandibular joint (TMJ) dysfunction. Again, if it is difficult and/or painful to chew, eating becomes an unpleasant chore. Radiation and chemotherapy can cause inflammation and ulceration of the oral cavity including oral mucousitis/stomatitis which often results in pain and altered taste sensation. 

 Step three of swallowing is the pharyngeal stage: This stage involves moving the food/liquids from the base of the tongue to the esophagus. To understand why some laryngectomees have difficulty swallowing, it helps to understand what happens to the upper esophagus when the larynx is removed. Prior to laryngectomy, the back wall of the larynx is actually part of the front wall of the upper esophagus. When the larynx is removed, part of the front wall of the upper esophagus is also removed. The remaining tissue is sutured together. The result is a smaller, scarred and less flexible upper esophagus.  

 The development of a pseudo epiglottis or a diverticulum is common complication associated with laryngectomy.  A pseudo epiglottis or diverticulum is simply a pouch or a pocket that develops in the throat at the base/bottom of the tongue. This pouch has a tendency to collect foods. A full feeling in the throat during mealtime, a sensation that food is sticking in the throat, being regurgitated or brought back up into the mouth from the throat may indicate the development of a pseudo epiglottis. A second type of problem commonly occurring after laryngectomy relates to the tightness of the upper esophagus. Upper esophageal tightness can be related to the tightness of the surgical closure, the development of scar tissue or pharyngeal constrictor spasm. Excessive tightness results in difficulty passing food and sometimes even liquids, from the base of the tongue to the esophagus. Difficulty with excessive tightness can vary from very mild difficulties which require the laryngectomee to eat slowly or avoid certain foods to a complete inability to swallow liquids. This difficulty may be noticed immediately after being allowed to begin eating and drinking and may resolve or improve after the surgical site ?loosens-up? with repeated use or this difficulty may progressively worsen over months or years as a result of the development of scar tissue or spasm.

 Aspiration is a problem that is not uncommon in the laryngectomee population.  Aspiration may result in the development of pneumonia which can cause respiratory problems, that, in some instances, result in death. Although surgical separation of the respiratory tract from the digestive tract reduces the likelihood of aspiration, separation does not necessarily prevent aspiration. Some laryngectomees can and do aspirate as a result of a fistula.

 For our purposes, let us say there are two types of fistulas. One is the result of improper wound healing. This is a fairly common postoperative complication.  Items that have been swallowed can leak into the surrounding tissues or structures through the undesirable opening. This can result in aspiration and infection if the leakage is into the lungs and infection and wound breakdown if the leakage is into the surrounding tissue.

 The second type of fistula is a surgically created fistula. A tracheoesophageal puncture (TEP) is a surgically created fistula. The surgeon creates an opening between the trachea and the esophagus which may initially house a feeding tube and will eventually accommodate a voice prosthesis. Leakage through or around a feeding tube or voice prosthesis can result in aspiration. Aspiration can also result if the TEP tract is left empty because of accidental dislodgment of a feeding tube or voice prosthesis. Significant persistent coughing associated with eating/drinking may indicate aspiration. Visualization of leakage around the feeding tube or around/through a voice prosthesis is also a good indication that aspiration is occurring.  At a minimum, leakage around or through one?s voice prosthesis is going to result in coughing which will likely interrupt the mealtime experience. At the extreme, chronic leakage around or through the voice prosthesis can result in a bronchitis or pneumonia which will compromise respiratory function.

 Step four is the esophageal stage of the swallow. The esophagus is a muscular tube that contracts in a rhythmic motion, called peristalsis. Peristaltic waves move food and liquid along the entire length of the esophagus to the stomach. Damage to the X Cranial Nerve can disrupt the rhythmic movement resulting in impaired esophageal emptying. A hiatal hernia which results in narrowing of the lower esophageal opening can result in slow emptying of food and liquids into the stomach. They may ?stack-up? in the esophagus and back up into the oral cavity.  Pieces of food, generally meat or bread, may plug the opening to the stomach. Scar tissue can create strictures or pouches that can trap food making it very difficult to swallow. A hiatal hernia can often contribute to the development of Gastroesophageal reflux (GERD) or esophageal motility disorders. 

 Many laryngectomees are reluctant to report a difficulty in swallowing to their speech pathologist or physicians.  Excuses for this reluctance include: ?I didn?t want to bother anybody.?, ?As a laryngectomee, I figured it was just something I would have to put up with.?, ?I was worried I would have to have surgery again,? and the ever popular ?I was afraid my cancer was back and I just didn?t want to deal with it.?   Poor nutrition and insufficient hydration can result in malnutrition and dehydration.  Malnutrition and dehydration can result in a host of medical complications including weakness, confusion, anemia, sores in the mouth, hair loss, irregular heartbeat, difficulty fighting off illness and infections, wounds that will not heal, and even death.

 While there are some aspects of the feeding process that a laryngectomee may indeed just have to learn to cope with, many types of swallowing problems are amenable to treatment. As with most medical issues, it is best to immediately report difficulty to the members of the healthcare team. Patients should be routinely asked about their ability to chew, swallow and maintain their weight. The earlier the problem is identified the sooner the healthcare team can begin working toward a solution. 

 In part three of ?That?s a Hard Pill to Swallow?, we will explore the process of diagnosing and treating swallowing problems.

 The nature of the universe does not admit easily the concept of ?possessions? ? for several reasons, the most fundamental is that the universe is either falling toward an entropic state of sameness, and perhaps the most fleeting reason is that ?ownership? is transitory at best, and at worst, an illusion.

 When listing ?possessions? ? I seldom think of non-physical realities, that is, I think in terms of physical ownership.  And thus the question arises: do I own my voice?  Do I own it more or less or equally to my blood pressure, my respiration, or my immune system? ? There are so many things which, when they change, are much more catastrophic than the loss of a voice.  When our immune systems fail, the consequences are truly shattering ? as is the failure of most of our internal organs.  For most of these cannot be replaced; those that can, carry an additional weight beyond most of our comprehensions.  When pandemic neurological  failings swept across the world in the 1940?s and 1950?s ? many were relegated to living in wards of ?iron lungs? ? an existence that was the consequence of losing something far more ?valuable? than speech ? the ability to move nearly everything, including your lungs.  When you failed to move your lungs you might still live; however, when you failed to move your heart, you did not.

 Our bodies are multi-organ and multi-system collections which work, in a perfect world, in perfect harmony.  When we realize that these worlds are not perfect, we do things to compensate, like take vitamins or use vaccines and antibiotics to ward off or alleviate the consequences of some kind of imperfection ? either within ourselves or contained external to ourselves in the world around us. We take medicines to change our internal chemistry so that our lives can be more enjoyable.

 When one cannot compensate for the loss of a body system or function, that loss becomes the focal point of our lives.  We turn away from those around us, often even from our concepts of personal spirit, and we feel loss.

 But I would argue not a loss of possession, but the loss of some of our quality of life.  Being basically egocentric we give weight to our losses which often are not real ? but are only illusionary.  A full professor of Theoretical Mathematics would find the learning disabled person who could not comprehend the function of numbers, even on a most elementary level, the epitome of leading a life of disappointment piled on top of disappointment.  Even  more tragic would be the student who excelled at mathematics slipping on an icy sidewalk, suffering a traumatic brain injury, and within seconds losing the ability to do even the most mundane mathematical mutations. 

 And, yet, to the full professor of Shakespearian Literature, such an event would herald no such reaction.  If the student could read and think, even though he could not think through the processes of the mathematical modeling of the internal workings of the ?Man Made Universe?, it would be of little consequence.  The loss would not be of any possession considered ?valuable? within that person?s focus.

 Please notice that I use the word ?focus? ? because that is how we lead our lives: we are egocentric self-centered beings who more often than not believe our work to be of great importance, and that anything which interferes with the ability to do the work we view as important creates a great loss.

 You have come to believe that possession of certain traits makes you good or bad, worthwhile or worthless.  And if worthless, then it is because you are poor and, being poor, you have few possessions.  As a civilization grows, the ?possessions? you must have increase. At some point they take on more meaning than they should.  Do you have a big house in good repair, or a small house in good repair? ? These are demarcations of who you are and where you stand in a society ? and thus have external value.

 All things succumb to the laws of entropy.  Entropy says, simply, that unless you keep putting energy into a system, then that system will break down.  Wood rots, Rock turns to stones which turn to gravel which turns to sand which turns to dust and is blown off into space.  Our sun will run out of fuel and slowly die.  Our bodies will break down and then decay and soon will not even be ?ours? any more.  It will be part of the molecular structure of other life forms ? and then, perhaps, of other suns and solar systems.   As Carl Sagan so eloquently said during his series on The Cosmos ? ?We are made of ?star-stuff??.  And so it is, as the universe runs down, we change shape and form so many times that attributing value to a transient quality or feature of our bodies is silly.  Yes, perhaps rippling abs are nice but not many 80 year olds have them. Are they then less valuable? Do they, with their soft-gutted, un-rippled abdomens, have less value than before? Do they in any reality have or POSSESS less?  

 The answer is dependent upon how egocentric and self-centered you are.  Perhaps, too, how shallow you are.  I would argue that the ?quality? of the attribute has changed, and that is neither good nor bad.  We often think of old wine as very good, and young wine as very poor.  Most 10 year old white wines are undrinkable.  Many one year old red wines are undrinkable.  Many one year old white wines are sparkling and refreshing ? while many 10 year old reds take on a mellow velvetness that a one year old red cannot match even through present day chemistry.  It depends upon the character of our subject.

 In this case the subject is a voice.  To think that we have lost a ?valuable possession? is silly ? we are still able to communicate ? we can write ? we can gesture and make faces ? the ?quality? of our communication is what we choose to accept as good for us.  However, living in an ?other? centered society we often define ourselves in the ways we believe that others think of us.  So wrinkled skin is a sign of old instead of knowledge, gray hair is a sign of aging instead of an honorable ?gray badge of courage? ? and a faltering voice is a sign of nearing senility.  We place such silly values on things. When people reinforce these values, we believe them even more.  And when an expert tells us the same things, it only proves how correct everyone else is.

 We have lost our original voices, and for most of us it is not the change to a different voice that bothers us so much as the suddenness of the change.  We grow and our voices turn from baby voices into the voices of children, then older children, then we reach puberty and our voices change rapidly enough that we can often hear the changing tones. And they strengthen ? loud enough to be heard on fire ground or in battle ? or across a playground of yelling, screaming, running, playing children at recess after four days of rain. Even then, we have to compensate and we blow whistles.  I have a school-yard bell that has been in our family since my grandmother?s grandmother?s mother taught school in Northern Wisconsin. We compensate.  In earlier times, orators in their 70?s or 80?s were not still trying to speak to crowds of several hundred, since even when the crowds  were ?quiet?, it was difficult.  It took a strong voice then.  Now, however, we can use microphones to address and orate an audience of several tens of thousands, and with television and radio, even the weak voiced septuagenarian can be heard around the world.

 Now we bring all this together ? do we own our voices? I would say ?No, we don?t?.   There are those who would say we do but, even if we did own our voices, they would change over time, growing weaker and weaker, until there is the last death-bed whisper heard only by the one leaning close to hear the words.  All systems run down in time. They are never lost;  they just change form ? from ice to liquid to mold to soil to tree to house to dirt to water to vapor to clouds to snow to ice ? the circle is not round, but it is eternal. 

 We are faced with the sudden loss of a voice, which we have been told is the loss of one of our most valuable possessions.  Is the loss any less great if it happens over 10 years? 20 or 30 years?  What is the time limit that makes this loss a loss of both value and possession?   My dog hears me just fine without my electro-larynx.  And my sister can understand me when I speak into her ear without my electro-larynx.  

 So the ultimate question is: when is loss really a loss?  And my reply is when YOU feel it is a loss.  Not when others do, only when you do.  And how valuable is that loss?  Well, that is a decision YOU have to make and each person will make a different decision.  I have rugs in my home that are far older than America, older than most countries in Europe.  They could be considered a loss more grievous than my voice, for they are tribal art.  If you were given the choice of losing the ceiling of the Sistine Chapel or your voice ? to live a life as you do now, and to lose the several hundred square feet of an old painting that doesn?t even belong to you ? which would you choose?   Each person will answer differently.  Each person may feel free to substitute an equivalent religious icon of their faith and decide that if the choice was to destroy that icon, or to keep your voice, which would you choose?  Would the fact that a compassionate doctor told you how deeply personal your voice is, and how it defines the essence of who you are, and how sorrowful he was that you had to lose it, make a difference in your belief? ? What if the choice should be more personal ? not so far out there as the destruction of Saint Peters in Rome, or the Kabala in Saudi Arabia, or the Wailing Wall in Israel, or the Temple in Salt Lake City against keeping your voice. 

 What if the choice was very personal?  What if the choice was: would you decide to destroy your family or lose your voice? Would you say: well the destruction of my family is nothing near as bad as the destruction of my voice ? or given the choice, I?d give up my voice in an instant to save my family?  A value judgment was made ? the kind we make every day and one thing was weighed against another ? and that which held the most value was chosen over that which held the least value.  The choice was a personal one, not one really coerced.  All choices are that way. Should you stop at the red light or should you not stop.  The coercion is there but it isn?t really there. The repercussion could be anything from no consequence for what you choose, to near misses, a ticket, an accident or an accident with single or multiple injuries and deaths. You stopped, perhaps, not because of the value of your vehicle but because of the values you placed upon other actions and events. 

 Let?s recall that in the beginning we were talking about ?possession? ? and yet, stopping at a red-light may have had nothing to do with the value and possession of your vehicle but of something much more intangible ? and perhaps of far greater value than even your life ? the value of a CIVILization. 

 I would argue that we have lost nothing that we would not have lost anyway.  And we made a value decision which showed us, that no matter what others have to say ? that within OUR value system, and within OUR understanding of what it is to ?possess? something as ephemeral as an immune system or a visual system, we made a decision that was well within our ability to choose wisely.  Why would a perfectly healthy person chose a mixed green salad and light soup over a well hung piece of beef or fresh Alaskan Salmon, or stuffed quail wrapped in pancetta and served with wild rice ? maybe because even though they could ?possess? any or all of them, and even though the extrinsic value was greater for one than the other ? the internal value was a personal value and that one just FELT like having a green mixed salad with a light broth soup instead of the other choices.  No coercion is exerted, no duress felt.  One just feels like having a salad with soup.

 Some of us just felt like having a total even if there were other choices. So we made a decision, and it really didn?t involve anything that we owned and only had a value we believed it had.  I once said to my stock broker ? you know, sometimes the greater joy is in the ?expectation? of something, than the actually ?attaining? of that thing.  She said, how sad to feel that way.  I saw the greater value in not possessing but in the wanting to possess, and she saw the greater value in the actual possession.  If you took away from me that thing which had brought me so much joy in expectation once I had attained it, it would be of much less value to me.  If you took it away before I could attain it, then my sadness would be greater than having attained it.

 We each are different ? and I see that desire has two sides ? it is one of the forces which fuels and moves civilization, and it is that which fuels and destroys civilization. It can build or it can destroy ? and the decision is yours ? and the value you place upon it is yours. 

 Desire, a Buddhist Teacher once told me, is like a trap.  A bird flies up to the trap and looks at the food inside ? and even though the bird knows that it is a trap and will lead to it?s death, it?s desire is stronger and it goes for the food.  There is other food around, but the bird only saw that food and wanted only that food ? and so it lost its way to the illusions created by desire.

 While the ultimate goal may be to rise above all desire, the next best thing, I believe, is to use that desire to build something greater ? and not destroy what is there.  The forest falls to the city ? and yet, the city produces the ornaments and trappings of our present day civilization, including the computer upon which you are reading this, and the invisible power which fuels the multitude of machines which transmit these characters to your eyes.

 A voice is only as valuable as we chose it to be, just as any other thing is only as valuable as we choose it to be.  Our lives change constantly, seldom is the change as abrupt as losing your voice overnight or taking that first step into boot, or getting fired for the first time.  But we all lived through times of abrupt change and we have lived through the loss of something we never owned.

 And when you think of it, losing something you never owned is not as traumatic as losing something you really thought you owned and then found out you didn?t.  Like your voice.

 I teach for a living.  My voice is important to me ? and yet, a month after my total I was back in the classroom ? when I could have taken an 80% medical retirement and lived the rest of my life in front of a TV on a sofa not having to answer to anyone at all.  Teachers, perhaps most of all, believe that they ?own? their voices, that their voices are ?theirs? and that they are their voices.  I know that those thoughts crossed my mind ? and then almost immediately that other voice from deep inside said ? silly! ? YOU are no different now than before. I was a corpsman and a paramedic and teach special education so I can tell you from great experience that there is a lot more a person can lose than their voice.

 There are those who would disagree ? and there are those who would look at only the dark side.  I still feel that most of us are looking for a light ? a way to make sense of things ? a perspective that works for us.  By ?works for us? I mean a perspective that makes us not lose sight of the insignificance of our total in the grand scheme of things ? or even the moderate scheme of things, or even the small scheme of things.  People, who believe they are very big, find that they have no ?small scheme? of things to compare their adventure against, and so, it becomes a monumental event.  For most of us, it is just an event ? fortunate or unfortunate ? but the longer you have your total, the less it matters if it is fortunate or not. The only thing that remains is that you realize you had a total, and that is like discovering when you were a baby that you have two legs AND two arms! ? an amazing revelation when it happens but after a while, you find that it isn?t as astonishing as you once thought it was.