Mets to Spine (C1 & 2) Voice Affected

[Joni]

Hi Group,
I am experiencing mets in my upper spine (C1 & 2), lung and lymphs in my chest. Had Radiation last summer, but no change in my voice until the past couple of months. It has become worse. My onc is sending me to an ear, nose and throat doc, but can't get in for a couple of weeks. Has anyone else experienced anything like this? Started chemo a week ago, Herceptin and Taxotere, but it started before the chemo. Dr. said maybe it had something to do with the lymph nodes. I go see him tomorrow afternoon. I will stay with my mom after the treatment for a couple of days so will be away from my computer. I will look for responses either in the morning or when I get back on Sunday.
Thanks for all of you...a true blessing in this uncertain world of cancer.
joni

[al from Canada]

because of my personal circumstances but....if your onc doesn't have enough clout to influence a 2-week waiting period with the nose doc; you should get a new one. Let's face it, mets to the spine area should bump you to the head of any line! The way I figure it: Don't let anyone jepordize your health...

Good luck and stay in touch,
Al

[Joni]

Thank you Al,
I called in the request to his office who set up the appointment. I too think it is too long to wait, so will bring it up today with my onc. He is great in so many ways, and the best in my ins. plan so I must have faith in him. Believe me, I am asking questions all the time. The voice problem began litterly months ago after I got broncitis and then went away more than once but this past week it is a real strain to get the words out. Communication is one of the things I like to think I do best...
I will let you know what I find out. Just getting scary thoughts about cancer getting into my throat or larnex.

My Best,
joni

Why don't you see if your onc can just call the ENT and find out what tests he is likely to order anyway or see if your onc is willing to place the orders at least an MRI of your neck(not just C spine) ie, neck from front to back and top to bottom to see the relationship of the recurrent laryngeal nerve which supplies your voicebox to any lymph nodes or mets you may have in the area--the ENT can only look from the inside with fiberoptics--if there is something compressing this nerve or the largyngeal area from the outside inward he will probably not be able to see it throught the laryngoscope. The ENT is really looking to see if one or both of the halves of your voice box do not open/close well or if there is something on the voicebox itself which is causing this. If he does see that your voicebox is not opening or closing well, he will then only infer whether the problem is with the nerve and will not know exactly what is interfering with the nerve's function and its location . The nerve supplying your voice box could be impinged upon anywhere from the chest (near the aorta or subclavian vessel) to the neck, to the base of your skull ie, the area just above C2 where your head meets your neck. Your insurance company does not want to waste money getting MRIs of all these areas if there is a nodule on your vocal cord causing the problem. But with your mets in the cervical spine and chest it is probably more likely the hoarseness is due to those rather than a nodule. It would actually best if your onc orders the MRI of your chest as well as the recurrent laryngeal nerve is a branch of the vagus nerve and begins in the thoracic near the arch of the aorta and the origin of the subclavian arteryl With your history of involvement of the chest, it is probably more likely that the nerve is involved down there than in your neck--your involvement there is very high ie, C1 AND C2 which could imply involvement of the base of the skull although it is less likely. The complete radiologic work-up would seem to include MRI (or CT---MRIs usually show soft tissues better, but CTs have greater resolution ie, can see smaller things as their cuts are much closer together--think of the difference in thickness of English muffins vs. white bread vs party rye) of the base of the skull, neck and upper chest

These orders could be placed and the authorizations obtained so that by the time the ENT sees you he could rule out a simple nodule on the vocal cord or the like and have you go right away for these studies.

So, The ENT will probably order an MRI of the Neck and/or chest/ and/or base of skull anyway--if you get it/them or at least authorization to get them before it will speed things up.( Sounds like you are a member of an insurance that requires pre-authorization-- there is nothing like getting things going early to speed things up.)

Are you being treated anywhere near a teaching hospital--there are new fancy ways to follow/trace nerves radiologically to determine where in their course they are being impinged upon.

I include some info to hand to your oncologist, in case it has been a long time since he finished anatomy lab in first year medical school and is not “fresh” regarding the anatomy of the nerves which supply the vocal cord.

He may not want to order too many tests, but if he could just call the ENT and ask him which tests he will probably order anyway, you could get started on ordering/getting authorization or possibly having some of them prior to seeing the ENT.

The info below is from a quick Google search. Sorry if this sounds disjointed or repetitive, but it did the post piecemeal. Caveat: obviously I am not an ENT!!

Good luck!




The recurrent laryngeal nerve is derived as a branch of the vagus nerve, on the left side as it passes the arch of the aorta and on the right side as it passes the subclavian artery. Upon reaching the larynx, it becomes the left and the right inferior laryngeal nerve and it passes at the posterior aspect of the cricothyroid joint. These branches communicate with the internal branch of the superior laryngeal nerve posterior to the cricoid cartilage; this is referred to as the ansa galeni.
Motor supply: With the exception of the cricothyroid muscle, the inferior laryngeal nerve supplies all the intrinsic muscles of the same side and the transverse arytenoid muscles bilaterally. Moreover, both the left and the right branches supply the trachea and the esophagus while traveling superiorly.

Clinical examination including indirect laryngoscopy and/or direct fiberoptic laryngoscopy is used to evaluate the patient with hoarseness for laryngeal mass lesions and vocal cord palsies. If vocal cord paralysis is seen, if focused clinical examination (including evaluation of cranial nerve function) demonstrates recurrent laryngeal nerve dysfunction, and if no laryngeal mass lesion is identified, then additional imaging may help to further localize and define the causative lesion. However, the underlying etiology may not be determined in approximately 10% of patients who present with vocal cord paralysis.
The course of the recurrent laryngeal nerve extends to the aortopulmonary window on the left and to the level of the subclavian artery on the right. A chest radiograph may provide helpful information in screening for lesions in these locations. If the chest radiograph does not reveal an abnormality that explains the clinical findings satisfactorily, as in this case, more sophisticated imaging is required. For evaluation of the infrahyoid part of the neck, enhanced computed tomography provides both excellent spatial and soft tissue resolution.
Isolated hoarseness/vocal cord paralysis may be due to lesions involving either the recurrent laryngeal or the superior laryngeal nerve, both of which are branches of the vagus nerve. The recurrent laryngeal nerve innervates all muscles of the larynx except the cricothyroid muscle. Recurrent laryngeal nerve dysfunction is the most common cause of vocal cord paralysis. If this is clinically suspected, then imaging should include the lower neck. If the palsy is left-sided, imaging should be continued caudally to the level of the aortopulmonary window. If the palsy is right-sided, imaging should be performed to the inferior aspect of the right subclavian artery. The superior laryngeal nerve preserves function of the cricothyroid muscle. If superior laryngeal nerve palsy is clinically suspected, then imaging should include the base of skull/posterior fossa and the upper neck. If the nerve involved is unclear, then imaging should cover the skull base/posterior fossa through the aortopulmonary window.


Laryngeal nerve palsy is damage to the recurrent laryngeal nerve (or less commonly the vagus nerve) that results in paralysis of the larynx (voice box). Paralysis may be temporary or permanent. Damage to the recurrent laryngeal nerve is most likely to occur during surgery on the thyroid gland to treat cancer of the thyroid. Laryngeal nerve palsy is also called recurrent laryngeal nerve damage.
The vagus nerve is one of 12 cranial nerves that connect the brain to other organs in the body. It runs from the brain to the large intestine. In the neck, the vagus nerve gives off a paired branch nerve called the recurrent laryngeal nerve. The recurrent laryngeal nerves lie in grooves along either side of the trachea (windpipe) between the trachea and the thyroid gland.
The recurrent laryngeal nerve controls movement of the larynx. The larynx is located where the throat divides into the esophagus, a tube that takes food to the stomach, and the trachea (windpipe) that takes air to the lungs. The larynx contains the apparatus for voice production: the vocal cords, and the muscles and ligaments that move the vocal cords. It also controls the flow of air into the lungs. When the recurrent laryngeal nerve is damaged, the movements of the larynx are reduced. This causes voice weakness, hoarseness, or sometimes the complete loss of voice. The changes may be temporary or permanent. In rare life-threatening cases of damage, the larynx is paralyzed to the extent that air cannot enter the lungs.
Causes
Laryngeal nerve palsy is an uncommon side effect of surgery to remove the thyroid gland (thyroidectomy). It occurs in 1% to 2% of operations for total thyroidectomy to treat cancer, and less often when only part of the thyroid is removed. Damage can occur to either one or both branches of the nerve, and it can be temporary or permanent. Most people experience only transient laryngeal nerve palsy and recover their normal voice within a few weeks.
Laryngeal nerve palsy can also occur from causes unrelated to thyroid surgery. These include damage to either the vagus nerve or the laryngeal nerve, due to tumors in the neck and chest or diseases in the chest such as aortic aneurysms. Both tumors and aneurysms press on the nerve, and the pressure causes damage.

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ENT LINK*>*ENT Health Information*>*Throat*>*Fact Sheet: Vocal Cord Paralysis*
Fact Sheet: Vocal Cord Paralysis

What Is Vocal Fold (cord) Paresis And Paralysis?
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Vocal fold (or cord) paresis and paralysis result from abnormal nerve input to the voice box muscles (laryngeal muscles). *Paralysis is the total interruption of nerve impulse resulting in no movement of the muscle; Paresis is the partial interruption of nerve impulse resulting in weak or abnormal motion of laryngeal muscle(s).
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Vocal fold paresis/paralysis can happen at any age – from birth to advanced age, in males and females alike, from a variety of causes. The effect on patients may vary greatly depending on the patient’s use of his or her voice: A mild vocal fold paresis can be the end to a singer's career, but have only a marginal effect on a computer programmer's career.

What Nerves Are Involved In Vocal Fold Paresis/Paralysis?
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Vocal fold movements are a result of the coordinated contraction of various muscles. These muscles are controlled by the brain through a specific set of nerves. The nerves that receive these signals are the:
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Superior laryngeal nerve (SLN), which carries signals to the cricothyroid muscle, located between the cricoid and thyroid cartilages. Since the cricothyroid muscle adjusts the tension of the vocal fold for high notes during singing, SLN paresis and paralysis result in abnormalities in voice pitch and the inability to sing with smooth change to each higher note. Sometimes, patients with SLN paresis/paralysis may have a normal speaking voice but an abnormal singing voice.
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The recurrent laryngeal nerve (RLN) carries signals to different voice box muscles responsible for opening vocal folds (as in breathing, coughing), closing vocal folds for vocal fold vibration during voice use, and closing vocal folds during swallowing. The recurrent laryngeal nerve goes into the chest cavity and curves back into the neck until it reaches the larynx. Because the nerve is relatively long and takes a "detour" to the voice box, it is at greater risk for injury from quite different causes – such as infections and tumors of the brain, neck, chest, or voice box; as well as complications during surgical procedures in the head, neck, or chest regions – that directly injure, stretch, or compress the nerve. Consequently, the recurrent laryngeal nerve is involved in majority of cases of vocal fold paresis or paralysis.

What Are The Causes Of Vocal Fold Paralysis/Paresis?
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The cause of vocal fold paralysis or paresis can indicate whether the disorder will resolve over time or whether it is most likely permanent. When a reversible cause is present, surgical treatment will most likely not be recommended given the likelihood of spontaneous resolution of the paresis or paralysis. **Despite advances in diagnostic technology, physicians are unable to detect the cause in about half of all vocal fold paralyses. These cases are referred to as idiopathic (due to unknown origins). In idiopathic cases, paralysis or paresis might be due to a viral infection affecting the voice box nerves (RLN or SLN) or the vagus nerve, but this cannot be proven in most cases. Known reasons for injury can include:
• Inadvertent injury during surgery: Surgery in the neck (e.g., surgery of thyroid gland, carotid artery) or surgery in the chest (e.g., surgery of the lung, esophagus, heart, or large blood vessels) may inadvertently result in RLN paresis or paralysis. The SLN may also be injured during head and neck surgery.
• Complication from endotracheal intubation: Injury to the RLN may occur when breathing tubes are used for general anesthesia and/or assisted breathing (artificial ventilation). However, this type of injury is rare, given the large number of operations done under general anesthesia.
• Blunt neck or chest trauma: *Any type of penetrating, hard impact on the neck or chest region may injure the RLN; impact to the neck may injure the SLN.
• Tumors of the skull base, neck, and chest: *Tumors (both cancerous and non-cancerous) can grow around nerves and squeeze them, resulting in varying degrees of paresis or paralysis.
• Viral infections: *Inflammation from viral infections may directly involve and injure the vagus nerve or its nerve branches to the voice box (RLN and SLN). Systemic illnesses affecting nerves in the body may also affect the nerves to the voice box.

What Are The Symptoms Of Vocal Fold Paralysis/Paresis?
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Both paresis and paralysis of voice box muscles result in voice changes and may also result in airway problems and swallowing difficulties.
• Voice changes: Hoarseness (croaky or rough voice); breathy voice (a lot of air with the voice); effortful phonation (extra effort on speaking); air wasting (excessive air pressure required to produce usual conversational voice); and diplophonia (voice sounds like a "gargle").
• Airway problems: Shortness of breath with exertion, noisy breathing (stridor), and ineffective or poor cough.
• Swallowing problems: Choking or coughing when swallowing food, drink, or even saliva, and food sticking in throat.

How Is Vocal Fold Paralysis/Paresis Diagnosed?
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The otolaryngologist—head and neck surgeon will conduct a general examination and then question you regarding your symptoms and lifestyle (voice use, alcohol/tobacco consumption). The examination of the voice box will be undertaken to determine whether one or both vocal folds (cords) is/are abnormal. Determining whether one or both vocal folds are affected is important in the treatment plan. Other tests may be required:
• Laryngeal electromyography (LEMG): LEMG measures electrical currents in the voice box muscles that are the result of nerve inputs. Measuring and looking at the pattern of the electric currents will indicate whether there is recovery or repair of nerve inputs (re-innervation) and the *degree of the nerve input problem. **The test involves the insertion of small needles that can measure electrical currents in the vocal fold muscles. During LEMG patients perform a number of tasks that would normally elicit characteristic actions in the tested muscles.
• Other tests: Because there is a wide list of diseases that may cause a nerve to be injured, further testing is usually necessary (blood tests, x-rays, CT scans, MRI, etc.) to identify the cause(s) of vocal fold paresis/paralysis.

What Is The Treatment For Vocal Fold Paralysis/Paresis?
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The two treatment strategies to improve vocal function are voice therapy, the equivalent of physical therapy for large muscle paresis/paralysis; and phonosurgery, an operation that repositions and/or reshapes the vocal fold(s) to improve voice function. *Normally, voice therapy is a first treatment option. After voice therapy, the decision for surgery is dependent on the severity of the symptoms, vocal needs of the patient, position of paralyzed vocal folds, prognosis for recovery, and cause of paresis/paralysis if known.
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If you have notice any change in voice quality, immediately contact an otolaryngologist—head and neck surgeon.

Vocal Cord Paralysis (PDF version)

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[Cheryl E]

Joni,
I see you live in Tucson. The University has one of the TOP speech and hearing departments in the country! This dept. also deals with rehabilitation of voice disorders. You might try calling the speech clinic on campus for a good ENT referral with regard to voice disorders. Ask if Dr. Dan Boone is still doing consultations. He is a voice expert. He is retired, but still researches and publishes. The clinic is also connected with the University Med Center.

Cheryl

Cheryl, there is a lot of info but just wanted to say that 2 week wait does seem a bit long for someone with stage IV b.c. and Her2+ However, perhaps dr. isn't concerned that it is 'serious' or that cancer is causing it, although that does need to be ruled out. One other thought--voice change might be delayed reaction from radiation. I think change in voice may also be associated with thyroid and that may have been affected if radiated. Take care and wishing you the best! Peace and {{{hugs}}}

[HavahJ]

YES! I thought I was the only one. Just discovered bone mets at top of spine(left occipital clivis). I didn't have symptoms but my marker went up a little so we did a pet scan. Onc isn't totally sure it's mets but pretty sure. It's my first met. I did ten times of peacock radiation and will find out if it worked in March. In the mean time will go to Mayo because if it grows they do surgery to take it out because there is no room in there for it to grow. It is really scary, so close to the brain and all, and so difficult to biopsy. I've been dealing with the same thing! Just write if you want to talk. Take care, Jan (HavahJ)

[Joni]

Wow, you are all so wonderful to reply. I am just getting back to my computer so decided to print out your responses and read up while I sit comfortably. I will get back with you after. I will say that I have a recent MRI for the docs to look at....more later.
joni from Tucson

[Joni]

Game plan, with ammunition ~ unregistered guest
You are very well informed and speak as though you may be a doctor. I appreciate your thorough response and will be prepared to ask questions and see what I can do in advance. I have had a recent MRI of my neck ...however, did they order it to be done from front to back and top to bottom? don't know. At the same time I had a CT of my chest and abdomen. I don't know my onc's knowledge of the anatomy of the nurves that supply the vocal cords, but my son, a recent Baylor PT grad and his wife an even more recent Duke grad and a P.A. may have some insight they can share with me.
Thanks "Doc"?
joni

[Joni]

Thank you Cheryl,
Yes, UMC is where I went for my original care in 1997. Ins has changed so unable to get coverage there, but my current doc use to be there and he does confir with my orig doc when I ask and/or on his own and will volunteer that he has talked with her. Also, I have been a patient of the team of Dr. Andrew Weil/Dr. Victoria Maizes from the UofA Integrative Med since 1998. There I do pay out of pocket. I will see who they recommend for a referral. Thank you for this info Cheryl. Where do you live?

My best to you,
joni
IP: 66.27.145.68

[Joni]

Hi Jan,
I don't know what to call the place where I have the ca in my spine other than C1 & C2. I need an anatomy book badly!! I have never heard of peacock radiation either. This is my first met also. Still learning the jargon. At Mayo what will they take out, just the cancer I hope. Radiation sounded like the only thing they could do for me with regard to the neck. Yes, lets keep in touch Jan. Where do you live? Which Mayo clinic? I will keep you in my prayers and will be on-line checking for messages as long as I can comfortable be at the computer. Does it bother you to be on very long?
My, I like to talk, and the thought of my voice being compromised really would put a crunch in my life if it were permanent. We will think good thoughts for us to be soon shouting from the mountaintops!!!!!!
My Best,
joni

[Cheryl E]

I live in orange county, ca. Have always been a so cal girl. Went to UofA for graduate work and then returned to CA.

Often MRIs are done of the Cspine looking especially at the vertebral bodies (bones) and discs. When done on cancer patients they are be done with attention (highest resolution to be sure not to miss areas of interest) from the front of the neck--thyroid and lymph nodes, through the middle of the neck-- trachea and esophagus, with areas through which the recurrent laryngeal nerve passes, as well as the "back" vertebral bodies, discs, spinal cord and ligament.

Other things can make one "hoarse" including reflux into the esophagus, the famous "GERD', nodules on the vocal cord, etc. So having the ENT exam is the right way to go--not everything in a cancer patient is cancer (or cancer-related due to problems resulting from treatment). An ENT should be the best person to sort things out.

I hope Strategic planning speeds things up!

[Joni]

Hi Cheryl, I too am a so CA girl. Born in Laguna and raised in Costa Mesa ~ CMHS grad of 1964. Small world. Where did you go to school in CA?
My Best,
joni

[Joni]

Thank you Guest,
I am going to see the neurosurgeon tomorrow morning and I hope to get a good interpretation of the MRI that my onc requested from the neu. I am printing out your responses and will share the knowledge you have offered to better understand what is happening to me.
My Best to you,
joni

[Cheryl E]

Joni,
Looks like you graduated the year after I was born! I grew up in Ventura , went to UCSB, then UA and have lived in city of Orange since graduating UA in 1987. Will be rooting for the Wildcats vs. UCLA this weekend.

[Joni]

Cheryl,
Ata Girl...U of A
joni