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AHNS- Soroush Zaghi- Dysphagia
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Early clinical factors associated with long-term impaired dysphagia-specific quality of life after free-flap reconstruction of oral cavity and oropharyngeal defects.
Presented by: Soroush Zaghi, MDResident Physician, PGY3UCLA Dept of Head and Neck SurgeryDavid Geffen School of Medicine at UCLALos Angeles, CA
Co-Authors: Doug Sidell, MD ; Keith Blackwell, MD ; Andrew Erman, MS; Vishad Nabili, MD
AHNS 8th International Conference on Head & Neck CancerToronto, CanadaSunday, July 22, 2012.
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AHNS Disclosure Slide
• Soroush Zaghi, MD: Nothing to disclose.
• Doug Sidell, MD: Nothing to disclose.
• Keith Blackwell, MD: Nothing to disclose.
• Andrew Erman: Nothing to disclose.
• Vishad Nabili, MD: Nothing to disclose.
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Dysphagia in head and neck cancer
• Dysphagia is a significant morbidity of head-and-neck cancer treatment.
• Dysphagia severity correlates with worsened QOL, increased anxiety and depression.
• Nutritional support, physical therapy, speech rehabilitation, pain management, and psychological counseling are available to help.
• Goal: Identification of patients at risk of dysphagia.
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“Risk factors predicting aspiration after free flap reconstructionof oral cavity and oropharyngeal defects.”
Smith JE, Suh JD, Erman A, Nabili V, Chhetri DK, Blackwell KE. Archives of Otolaryngol ogy- Head Neck Surg. Nov 2008;134(11):1205-1208.
• 100 patients s/p resection of oral cavity or oropharyngeal tumors with immediate free flap reconstruction
• Modified barium swallow study (MBSS) at approximately one month post-operatively to assess dysphagia severity.
• High risk of having early postoperative aspiration after free flap reconstruction:– Patients with prior history of radiation therapy– Patients with resection of more than half of the tongue base
• Conclusion: Patients with h/o XRT or > 50% tongue base resection should be considered candidates for perioperative gastrostomy tube placement.
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Limitations of Prior Study
• MBSS outcomes are a reliable indicator of swallowing function for the short-term post-operative setting (3-6 months).
• Immediate post-op MBSS results may not be a reliable predictor of long-term dysphagia outcomes.
• Progressive improvement in head and neck– dysphagia specific quality of life over a period of at least 12 months after the completion of treatment.
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Objective
To further determine the subsequent dysphagia-specific quality of life among this population of patients at > 1 year follow-up after surgery.
To identify early clinical factors associated with poor long-term dysphagia outcomes.
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Methods
• M.D. Anderson Dysphagia Inventory (MDADI) surveys were sent to the 100 patients included in the previously published study.
• Inclusion criteria: Patients who were (1) greater than or equal to 12 months post surgery and (2) gave complete responses to the survey questionnaire.
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MD Anderson Dysphagia Inventory• Cross-validated questionnaire designed specifically to assess dysphagia QOL in patients with head and
neck cancer.
• 21 dysphagia-related statements, subdivided into four subscales:
– Global Score- single question: “my swallowing ability limits my day-to-day activities” (A general overall assessment.)
– Emotional Subset: emotional responses to dysphagia. (e.g. “I am embarrassed by my eating habits; I am upset by my swallowing problem”.)
– Functional Subset: impact of swallowing problem on daily activities. (e.g. “It takes me longer to eat because of my swallowing problem; my swallowing problem limits my social and personal life ”.)
– Physical Subset: represents self-perceptions of the swallowing difficulties (e.g.” swallowing takes great effort, I feel that I am swallowing a huge amount of food; I cough when I try to drink liquids”)
– Total Score: sum of Emotional, Functional, Physical subsets
MDADI scores set to scale: Higher score= better day to day functioning greater quality of life 0 = (extremely low functioning) 100 = (extremely high functioning)
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Results• Twenty-two responses met the
inclusion criteria and were included in the analysis.
• MDADI surveys were completed between 524 to 1968 days after surgery (median: 820 days).
• MBSS was performed between 13 and 58 days post-operatively (median: 33 days).
• Of the 22 patients included in the analysis, 9.1% (n=2) still had a G-tube at the time of survey.
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Primary Findings:- Prior h/o radiation therapy: Significantly associated with
lower MDADI scores at long-term follow up across ALL subscale domains.
- Greater than 50% tongue base resection: No significant association with any MDADI score.
E.g. Total Score- Yes (n=7) : 64.9 ± 7.5 vs. No (n=15): 63.3 ± 5.1, p=0.8628.
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Secondary Findings:• Certain findings on early postoperative MBSS may be predictive of
long-term dysphagia outcomes.
– Specifically: evidence of aspiration and severely impaired oral phase swallowing.
– Other facets of the MBSS (e.g. oral preparatory phase, pharyngeal phase, penetration, aspiration risk), on the other hand, correlated poorly with long-term QOL outcomes
• Gender- Women were significantly more likely to report more critical self-perceptions of swallowing difficulties.
• Surgical Defect- Resection of lateral pharyngeal wall and/or soft palate may have long-term effect on post-op dysphagia.
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Limitations• A large proportion of patients from the previous study were lost to
follow up. This phenomenon was expectedly true among patients with advanced T- stage malignancies.
• Small sample size- power limiting considerations. – Differences in quality of life scores corresponding to a 20% difference were
considered clinically significant (a sample size of 22 can be used to distinguish groups with a 20-point anticipated difference in means with power= 80%, Type 1 error= 0.05).
• Many of the associations reported were discovered with univariate exploratory analysis- inherent weakness in terms of Type I error, but good for hypothesis generation and identifying variables for future studies.
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ConclusionPatients with:
history of radiation therapy, early post-operative evidence of aspiration, difficulty with oral phase of swallowing, defects at lateral pharyngeal wall/soft palate, women in general.
– Risk of of poor long-term dysphagia QOL MDADI outcomes
– Should be the subject of further dysphagia-related research – May be directed early on to multidisciplinary teams to help them overcome and
cope with swallowing dysfunction.