department of otolaryngology-head and neck surgery ... · –result of surgical resection and...

10/13/20

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CHANGING MEDICINE.CHANGING LIVES.®

Dysphagia Evaluation in HNC PopulationsBrian Peterson, MA, CCC-SLPOctober 2020

Department of Otolaryngology- Head and Neck Surgery

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Objectives• Learners will:

– Gain information related to overarching goals of dysphagia management in HNC population

– Gain information on the impact of various surgical management options on swallow function

– Gain information on the UIHC SLP C/RT dysphagia clinical pathway– Gain information regarding the support for SLPs in the multidisciplinary

HNC team


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HNC Dysphagia

• Can be related to:– Tumor burden– Result of surgical resection and reconstruction– Acute effects of C/RT – Late-onset tissue fibrosis– Cranial nerve neuropathies


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HNC Dysphagia

• Regardless of treatment approach for HNC, swallow function will rarely return to normal, without ANY long-term side effects

• Goals need to be patient-centered, realistic, and evidence-based

• May need to shift mindset, becoming “okay” with some aspiration with strategies to maximize swallow function/PO while limiting risk for aspiration related complications


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Goals of Assessment(s)• Know as much as possible prior to start of treatment

– Single modality vs multi-modality– Surgical plan and/or op note, if available– Radiation plan- at least # of treatments and areas targeted

• Be involved prior to treatment – Educate regarding possible/anticipated challenges– Initiate prophylactic strategies/exercises as indicated

• Assess for dysphagia and develop treatment plans


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Impact of Surgery

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Tracheostomy• Artificial airway placed through anterior neck into trachea


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Tracheostomy & Dysphagia• Presence of tracheostomy tube

can affect swallowing:– Reduced hyolaryngeal

elevation/excursion– Reduced subglottic air

pressure– Reduced upper airway

sensitivity


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Tracheostomy & Dysphagia• Passy-Muir Valve

– One-way, closed position valve– Re-directs air up through larynx/pharynx– Re-establishes “closed system”


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Impact of Surgery• Extent of dysphagia after surgery depends on what/where/how

much resected• Depends on manner of resection

– Open procedure– Robotic Surgery– Laser

• Depends on manner of closure– Primary closure– Reconstruction


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Impact of Surgery


Oral surgery may result in dysphagia d/t resection and reconstruction

Tongue surgery -lingual range of motion, control, and strength may be effected depending on the extent of the surgery

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Oral Surgery• Therapeutic Strategies

– Head position (chin tuck/chin extension)– Super-Supraglottic Swallow– Adaptive utensils/dishes


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Partial Laryngectomy

• Dysphagia varies based on the area/extent of reconstruction and resection

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Partial Laryngectomy• Therapeutic Strategies

– Head Turn– Super-supraglottic swallow– Swallow, cough, re-swallow– Liquid modifications– Diet modifications

• BioFEESback can be very beneficial for these patients


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Total Laryngectomy• Larynx and supraglottic structures surgically removed (true

vocal folds, ventricular folds, epiglottis, hyoid bone)• Neopharynx created with primary closure or reconstruction• Trachea re-routed to the anterior neck to form a stoma


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TL & Dysphagia• Impairments related to total laryngectomy may include:

– Reduced BOT-PPW contraction– Reduced neopharyngeal contraction – especially in cases requiring flap

reconstruction– Reduced UES opening

• Compensatory Strategies:– Moist/slick foods– Utilize liquid wash– Head turn to one side or the other

• “Silver Lining”– Unless a fistula develops, patient can no longer aspirate*– Many patients return to a fairly normal diet


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Impact of Surgery• Regardless of type of surgical procedure, important to get

instrumental swallow study to establish new swallow function baseline, risk of aspiration, and potential benefit of compensatory strategies


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Impact of Radiation +/- Chemo

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Dysphagia Associated with RT +/-

Chemo

• A common effect with estimated prevalence of 39-64% after RT or CRT (Hutcheson, 2013)

• A common complication for patients both acutely and long after treatment has ended (Kotz et al., 2012)

• Evidence to support that severity of dysphagia depends on dose to relevant swallowing structures (i.e., pharyngeal constrictors, esophageal inlet, glottic and supraglottic larynx) (K. Wopken et al., 2018)


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Importance of SLP

Involvement

• Evidence to support that multidisciplinary care for patients with HNC can result in better patient outcomes (Messing et al, 2019)

• SLP’s involvement throughout the continuum of patient care promotes best functional outcomes and best practices in HNC (Starmer & Edwards, 2019)

– Enhance buy-in by providing patient/caregiver counseling and rationale as well as potential benefits to exercise regimen (Paleri et al, 2014)

– Can positively impact patient attendance and adherence to swallowing recommendations (Starmer, 2014)


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UIHC SLP RT +/- Chemo Dysphagia Protocol• Pre- treatment:

– Initial swallowing evaluation/education

• During treatment:– Weekly/Bi-weekly follow-up (max. 30 minutes) sessions

• Post-treatment:– Coordinated follow-ups with return appts to other teams– Repeat clinical assessments and instrumental assessments, as

indicated– Therapy and/or appropriate referrals as indicated


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RT +/- Chemo Dysphagia Management –Pre-treatment

• Goals:– Establish relationship/rapport prior to

initiation of treatment• Establish patient goals

– Assess baseline swallow function, functional nutritional status, patient perceived dysphagia

• Poor correlation between measurable dysphagia and patient perception (Starmer, 2014)

– Provide education and management strategies re: anticipated treatment-related toxicities affecting swallow function and PO intake as well as swallow exercises


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Initial Speech-Language Pathology Visit

• Chart review: – Type, stage, location– Previous treatment – surgery, RT +/-

Chemo• If RT +/- Chemo, treatment plan (i.e., dose,

treatments, targeted areas)

• Patient interview: Reported dysphagia, need to modify foods/liquids, need for supplemental shakes/enteral nutrition

• Gather quantitative data regarding patient-reported dysphagia and PO intake


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Patient Self-Assessment Tools

EAT-10 (Belafsky et al., 2008)


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Patient Self-Assessment Tools

MD Anderson Dysphagia Index (MDADI)


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Clinician-Rated Assessments


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Clinician-Rated AssessmentsPerformance Status Scale- HNC (PSS-HNC)


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• Oral mechanism exam• Clinical/bedside swallow study• Possible instrumental swallow study via

Oropharyngeal Motility Study (OPMS) or Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

– May be recommended initially based on tumor location and/or stage


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OROPHARYNGEAL MOTILITY STUDY (OPMS)AKA: “COOKIE SWALLOW”• Instrumental evaluation of swallowing

using videofluoroscopy

• Administer barium of varying consistencies to assess oropharyngeal swallow function, risk of aspiration, and inform treatment planning

• Allows view of function in oral, pharyngeal, and esophageal phases before, during, and after swallow


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OROPHARYNGEAL MOTILITY STUDY (OPMS)AKA: “COOKIE SWALLOW”• Not a “pass/fail” evaluation

– Martin-Harris, et al (2000): review of 608 swallow studies-10.4% normal, 32.4% with aspiration, 57.2% abnormal but no aspiration

• Used as a therapeutic instrument to test benefit of compensatory strategies

• Used as a tool to maximize efficiency and safety of swallow function


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Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

• Instrumental assessment using flexible laryngoscope

• Administer real food consistencies dyed an artificial colorto assess oropharyngeal swallow function, risk of aspiration, and inform treatment planning

• Allows for view of anatomical structures and tissue

• Allows for view of presence/absence of pooled secretions

• Cannot view pharynx/larynx during a “normal swallow”


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Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

• Not a “pass/fail” evaluation• Used as a therapeutic instrument

to test benefit of compensatory strategies

• Used as a tool to maximize efficiency and safety of swallow function


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Not a ”pass/fail” evaluation!• Goal is to limit risk of aspiration-related complications, not JUST

to eliminate aspiration• Attempt strategies and/or maneuvers to maximize safety and

efficiency– Chin tuck, chin extension– Head turn L, R (+/- chin tuck)– (Super)Supraglottic Swallow– Double swallow– Effortful swallow– Swallow/cough/re-swallow


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Not a ”pass/fail” evaluation!• Educate other participants in the study about the rationale for

continuing despite observed aspiration


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• Oral mechanism exam

• Clinical/Bedside swallow study

• Possible instrumental swallow study via Fiberoptic Endoscopic Evaluation of Swallowing (FEES) or Oropharyngeal Motility Study (OPMS)


• Provide PO recommendations based on results and anticipated changes during treatment course – NPO as last resort

• Provide education regarding 3 main RT toxicities likely to affect swallowing/PO intake during treatment course

– Odynophagia (painful swallowing)– Dysgeusia/hypogeusia (taste changes/reduced taste)– Xerostomia (dry mouth)


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• Oral mechanism exam• Clinical/Bedside swallow study

• Possible instrumental swallow study via Fiberoptic Endoscopic Evaluation of Swallowing (FEES) or Oropharyngeal Motility Study (OPMS)


• Provide recommendations based on results and anticipated changes during treatment course

• Educate regarding 3 main RT toxicities likely to affect swallowing/PO

• Teach prophylactic swallowing exercises


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Prophylactic Swallowing Exercise Program

• Less PO intake = less resistive load on swallow musculature, proactive swallow therapy aims to maximize use of swallow musculature during RT or CRT (Hutcheson, 2013)

• Targeting swallowing habilitation vs rehabilitation

• Swallowing exercise program targets areas of impairment and/or areas most likely to be affected based on RT treatment plan

• Start prior to or as close to beginning of treatment as possible


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“Pharyngocise” – Carnaby-Mann, Crary, Schmalfuss, Amdur, 2012

• One of the first RCT of systematic program of swallowing exercises during CRT

• 58 HNC Patients– Oropharyngeal cancer– External beam radiation planned– No hx of non-oral feeding for cancer-related illness– Able to undergo MRI


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• Primary Outcome– Muscle size and composition determined by t2 –weighted MRI

• Secondary Outcomes– Functional swallowing ability, dietary intake, chemosensory function,

salivation, nutritional status, occurrence of dysphagia-related complications


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• 3 groups– ”Usual Care”– Sham – High-intensity swallow therapy group (“Pharyngocise”)


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• Primary Outcome Results– All groups demonstrated muscle deterioration during treatment, but

greatest preservation noted in Pharyngocise group for genioglossus, hyoglossus, and mylohyoid


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• Secondary Outcomes Results– Functional Swallowing- No significant difference

between groups, however better median score in Pharyngocise group

– Better maintenance of oral intake/less PEG tube placement in Pharyngocise vs usual care

– Less decline in taste and smell in Pharyngocisegroup

– Significant preservation of salivary flow in Pharyngocise group

– Weight loss not significantly different between groups– No significant associations between dysphagia-

related complications and treatment group


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–Conclusion• Results suggest participation in swallow exercise

program during C/RT yield better maintenance of head and neck musculature and improved functional swallowing outcomes

• Interestingly, benefits were seen in both Pharyngociseand sham groups


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“Use it or Lose it”- Hutcheson, et. al 2013

• Retrospective observational study• 497 HNC patients

– Pharyngeal cancer (oropharyngeal or hypopharyngeal)– Treated with RT or CRT


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“Use it or Lose it”- Hutcheson, et. al 2013

• Swallowing end-points: – Final diet after RT or CRT – Length of PEG dependence

• Independent variables: – Oral intake at the end of RT or CRT (no oral intake, partial intake, full

intake)– Adherence to swallow exercise program


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“Use it or Lose it”-Hutcheson et al 2013

• Final diet results– Eat + Exercise = 92%

regular diet at 24 months s/p fin

– NPO + no exercise = 65% regular diet at 24 months s/p fin


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“Use it or Lose it”-Hutcheson et al 2013• PEG Dependence

Results– NPO + no exercise =

median 222 days (33 – 1781)

– Partial PO + exercise = median 111 days (0 – 2029)


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Take Home Messages – Rad +/- Chemo• Involvement of SLPs can be beneficial to patient outcomes in

dysphagia associated with C/RT management of HNC• Ideal for patients to take full PO diet and full regimen of

swallowing exercises during C/RT, but some is better than none• Ongoing research is warranted to define/refine best practice

guidelines for best patient outcomes


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Take Home Messages• Dysphagia related to surgical management depends on a

variety of factors and visualization of swallow function is critical• Dysphagia related to radiation +/- chemo therapy is common

and our involvement can be very beneficial• Patient-centered care is important and overarching goals need

to be centered on maximizing PO and limiting risk of aspiration-related complications


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CHANGING MEDICINE.CHANGING LIVES.®

uihc.org

Questions?Brian Peterson, MA, CCC-SLPSpeech-Language Pathologist IIDepartment of Otolaryngology –Head and Neck Surgery

[email protected]


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References• Belafsky, P. C., Mouadeb, D. A., Rees, C. J., Pryor, J.

C., Postma, G. N., Allen, J., & Leonard, R. J. (2008). Validity and reliability of the Eating Assessment Tool (EAT-10). The Annals of otology, rhinology, and laryngology, 117(12), 919–924.

• Carnaby-Mann, G., Crary, M. A., Schmalfuss, I., & Amdur, R. (2012). "Pharyngocise": randomized controlled trial of preventative exercises to maintain muscle structure and swallowing function during head-and-neck chemoradiotherapy. International journal of radiation oncology, biology, physics, 83(1), 210–219.

• Crary, M. A., Mann, G. D., & Groher, M. E. (2005). Initial psychometric assessment of a functional oral intake scale for dysphagia in stroke patients. Archives of physical medicine and rehabilitation, 86(8), 1516–1520.


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References• Hutcheson, K. A., Bhayani, M. K., Beadle, B. M.,

Gold, K. A., Shinn, E. H., Lai, S. Y., & Lewin, J. (2013). Eat and exercise during radiotherapy or chemoradiotherapy for pharyngeal cancers: use it or lose it. JAMA otolaryngology-- head & neck surgery, 139(11), 1127–1134.

• Kotz, T., Federman, A. D., Kao, J., Milman, L., Packer, S., Lopez-Prieto, C., Forsythe, K., & Genden, E. M. (2012). Prophylactic swallowing exercises in patients with head and neck cancer undergoing chemoradiation: a randomized trial. Archives of otolaryngology--head & neck surgery, 138(4), 376–382.


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References• Messing, B. P., Ward, E. C., Lazarus, C., Ryniak, K., Kim, M.,

Silinonte, J., Gold, D., Thompson, C. B., Pitman, K. T., Blanco, R., Sobel, R., Harrer, K., Ulmer, K., Neuner, G., Patel, K., Tang, M., & Lee, G. (2019). Establishing a Multidisciplinary Head and Neck Clinical Pathway: An Implementation Evaluation and Audit of Dysphagia-Related Services and Outcomes. Dysphagia, 34(1), 89–104. https://doi.org/10.1007/s00455-018-9917-4

• Paleri, V., Roe, J. W., Strojan, P., Corry, J., Grégoire, V., Hamoir, M., Eisbruch, A., Mendenhall, W. M., Silver, C. E., Rinaldo, A., Takes, R. P., & Ferlito, A. (2014). Strategies to reduce long-term postchemoradiation dysphagia in patients with head and neck cancer: an evidence-based review. Head & neck, 36(3), 431–443.

• Starmer, Heather M. Dysphagia in head and neck cancer: prevention and treatment, Current Opinion in Otolaryngology & Head and Neck Surgery: June 2014 - Volume 22 - Issue 3 - p 195-200

• Starmer, H., & Edwards, J. (2019). Clinical Decision Making with Head and Neck Cancer Patients with Dysphagia. Seminars in speech and language, 40(3), 213–226.


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References• Wopken, K., Bijl, H. P., & Langendijk, J. A.

(2018). Prognostic factors for tube feeding dependence after curative (chemo-) radiation in head and neck cancer: A systematic review of literature. Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology, 126(1), 56–67.


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department of otolaryngology-head and neck surgery ... · –result of surgical resection and...

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