Approaches to Ax and Tx for the SLP for Patients with

Head and Neck Cancer

MEGAN HYERS, MS, CCC-SLP

REBECCA SCHOB, MS, CCC-SLP

PPMC Ampitheater

March 29, 2014

Dysphagia and XRT

3 phases of Treatment Before During After

“Few other cancers demonstrate the need for anticipatory Tx and rehab to the magnitude required in the management of head and neck cancer”

(Myers, Barofsky, and Yates. 1986)

Phase 1: Evaluation before XRT

Clinical eval of speech, voice, swallowing establish baselines optimize performance status implement strategies as needed determine need for further evaluation

Phase 1: Treatment before XRT Patient counseling

compare normal aerodigestive A&P discuss swallow, voice production, airway

management, trach review short- and long-term XRT sequelae

Swallowing Breathing Trismus  Mucositis Xerostomia

Intervention for Dysphagia

Order based on muscle effort, ease of application, ease of learning:

postures sensory stimulation swallow maneuvers diet modification

Pretreatment Dysphagia Protocol

Tongue exercises include passive range of motion and active assistive range of motion.

Tongue Hold Effortful Swallow Laryngeal elevation exercises: pitch glides

and vocalizing /i/ at a high pitch. Mendelsohn Maneuver and Shaker Exercises Jaw range of motion exercises: maintain

rotary movements of mastication and decrease the chance of trismus

Myofascial Release

Start pt working on their scar tissue – ASAP once staples removed, scabs have fallen off

Mobilizing the scar tissue may help prevent adhesions, reduced ROM, persistent pain, more significant effects of lymphedema

Promotes blood flow and blood vessel growth

Most benefit comes just below pain threshold

Use firm pressure, start gently and increase to deeper massage (see handout)

Desensitization

Trismushttp://oralcancerfoundation.org/dental/trismus.htm

Persistent contraction of the masticatory muscles due to hypovascularity or neural damage.

Prevalence:10%-40%

“Elevator Muscles” Temporalis Masseter Medial Pterygoid Lateral pterygoid

Trismushttp://oralcancerfoundation.org/dental/trismus.htm

Results in: Pain: muscle guarding Limited oral opening:

Difficulty wearing denturesDifficulty having dental work performedDifficulty with intubation for later

(elective) surgeries Dysarthria: decreased speech intelligibility Dysphagia: difficulty

swallowing/eating/drinkingReduced rotary masticationCan’t use spoon/fork, take bite of

sandwich etc.

Trismus Therapy

Stretching Systems : Tongue blades (short stretch) Therabite or Orastretch system (7x/day,

7reps, 7 seconds or 3x/day, 5 reps, 30 seconds)

Trismus stretching systems (cont)

Dynasplint Trismus System (DTS) prolonged stretch

Current study : randomized trials using stretching system for 3-6 months

Start 5-10 minutes, increase to 30-45 mins, 3x/day or maximum 90 mins/day

Once achieved, then increase tension

Trismus Therapy

Manual Treatments: Myofascial release Intra-/extra-oral palpation, stretching,

massage Oral aperture measurements

Female normal bite range is 35-38 mm Normal for an adult male is 45 to 50 mm Exercises should be continued for min: 1

year

Contraindications for Trismus

Pain Poor dentition Oral aperture of <10mm

Phase 2: during XRT

short-term: get pt through XRT (tolerate and maintain oral intake) compensatory strategies, swallow

maneuvers exercises regimen pain management desensitization therapy saliva substitutes diet changes

monitor w/subjective and objective evaluators.

Anticipate Acute Effects of XRT

edema dermatitis and

mucositis mild changes to

loss of taste xerostomia odynophagia erythema dysgeusia hypersensitivity decreased appetite

acute changes in swallowing occur

vocal deterioration (hoarseness pitch changes, vocal fatigue)

later: stiffness and

sensory loss pain and edema depression

Mucositis

Inflammation and ulceration of mucosal membranes

From XRT or Chemo If Chemo: Usually in 4-10 days If XRT: 2 weeks, may last 6-8 weeks

Results in Pain Dysphagia Bleeding Infection Change in taste Decreased appetite and PO intake

How

Development of Oral mucositis

WHO Grading of Oral mucositis

Mucositis http://www.caphosol.ca/health-care-professionals

Stage 1 (above) Stage 3 (below)

Stage 2 (above) Stage 4 (below)

Px & Tx of Oral Mucositis http://www.uspharmacist.com/content/s/172/c/29044

pretreatment dental examination improved dental hygiene

clean the mouth every 4 hours and at bedtime

more often if the mucositis worsens use a non-detergent toothpaste floss between the teeth use an alcohol-free mouthwash. Use

saline or baking soda mouthwash to soothe & clean the mouth

Tx of Oral Mucositis

Use artificial saliva, lozenges, gum to lubricate the mouth.

Suck ice chips Drink at least 3L/day Avoid citrus fruits, tomatoes, acidic

foods, alcohol, and hot foods that can aggravate mucositis lesions

Avoid hard, crunchy foods No smoking No alcohol

Treatments available

Saliva substitutes topical and oral medications Med Oral Oral Balance (gel) Mouthkote (lemon based) Salivart (oil based) Alcohol-free toothpaste/mouthwash

(biotene)

Treatment for Xerostomia

Sip water, ice chips Artificial saliva (rinse, spray) Suck on lozenges/candies (sugar free) Chew to stimulate saliva production (gum,

wax, etc) Moisten foods Avoid salty, dry foods, high sugar content

foods/drinks Avoid alcohol or caffeine, also acidic juices Aloe water, papya Netti bowl/pot, nasal saline lavage

Overall intervention techniques Mucositis/Xerostomia:

Oral hydration : mist bottles, humidifier, etc Dysgeusa/hypersensitivity

Desensitization therapy: utensils, taste, texture

Diet modifications Dysphonia

Vocal hygiene strategies Personal amplification (e.g., Chattervox)

Pureed… again?

Need variety!

Protein powders

Nut butters

Frozen veggies

Anything!

What can your blender handle?

Stress Management

Laughter!! Pacing and Rest (related to daily tasks

and eating) Guided meditation or relaxation Breaking down tasks, taking breaks Mindfulness practices What’s energy giving (music, pets,

walks, bath…) Basic stretches and mobility Discuss self-care, talking to someone

who can just listen

The Rule of 10Logeman, Sisson & Wheeler, 1980

To eat or not to eat? oral transit time and pharyngeal transit

time > 10 seconds, maintain PO but will need non-oral supplementation

aspiration > 10% , pts eliminate consistency

coughing, choking ? at10% pts stop eating but silent aspirators continue to eat

aspiration > 10% = non-oral feeding

When to TF?

If PO is good, wait for the problem if nutrition is poor before XRT, then

immediate weight loss greater than or equal to 5%

in less than or equal to 1 month or greater then or equal to 10% during XRT

Enteral Means of Nutrition

J-tube (jejunostomy) placed between the jejunum and surface of abdominal wall

G-tube (gastrostomy) placed in the stomach

PEG (percutaneous endoscopic gastrostomy) placed endoscopically

PFG (percutaneous flurosopic gastostomy) placed fluoroscopically

Dobhoff/N-G (naso-gastric) tube – place in nose and passed to esophageus

TPN (total parenteral nutrition) nutrients administered intravenously-bypass GI system

Why TF?

Optimize tx tolerance reduce complications related to poor

nutrition improve healing and recovery increase strength and energy enhance overall QOL Temporary!!

Made it!!

Phase 3: After XRT

re-eval speech and swallow when acute Sx have resolved

one month pt follow-up re-review effects of fibrosis swallowing exercises protocol begins and

may be continued for at least one year (5 mins sessions/10x/day)

evaluate and treat prn MBSS/VFSS or FEES if needed

Up the Ante for Dysphagia/Dysarthria Tx When able, use Biofeedback as much as

possible! FEES EMG monitoring for swallow strengthening Mirror Tactile feedback Record and self-evaluate for voice

Vital Stim (Neuromuscular Electrical Stimulation) If okay’d by physician No active neoplasm

Know your resources

Prostheodontists or denturist Palatal lifts, prosthesis for partial

glossectomy… Behavioral health, MSW

Smoking cessation Depression

Nutritionist Financial assistance

Return to work Support Groups Clergy

Weaning from TFs

Swallow must be safe and efficient Consider nutritional status pre-XRT Consider wt loss before/during XRT Reducing TFs – MUST maintain adequate

nutrition/caloric intake and hydration

Make a plan

Pt’s frequent complaint: lack of appetite small frequent meals 5-7 meals /day carry snacks Goal of eating every hour consider what else effects appetite:

taste loss dysphagia Constipation, diarrhea reduced enjoyment

Barriers

Mental Anxiety about swallowing d/t past

pain/difficulty Effort (cooking time, eating time,

swallowing strategies, calorie counting, etc)

Feelings of isolation, everyone finished before me at meals, food gets cold, not enjoyable anymore

Most difficult to rehab: one who eats only 1 meal/day, lives alone, etc

In Practice:

The Soft Skills are the most important Motivational Interviewing Listen for the individual’s needs: emotional

will likely come before physical goals/motivation to eat a type of food,

go out to eat with friends, upcoming holiday meal

ID the support system and get them involved

eat first thing in the morning BEFORE TF so one has an appetite, normal routine…

Try the scariest foods together in sessions

Assessment and Treatment for the SLP

Lymphedema

Lymphedema

Accumulation of fluid that is relatively high in protein content

Often found in H&N Cancer following surgery or XRT

Dx made by physician, not SLP  Why are we looking? Why is it

important? Edema may exacerbate dysphagia Negatively impacts QOL

Prevention of lymphedema

Trach tie should be 1 finger loose as long not

moving can create turniquet effect lump/bump can induce swelling above trach tie if too

tight if too loose, may cause coughing and pt

may be resistant

Medical Hx

reveals clues re: lymphedema vs other edema

fluctuations in edema onset of edema vs Tx/trauma physical characteristics of edema medical contraindications to Tx? Physical limitations for implementations? Post-XRT fibrosis of neck

Timing

how long since surgery, xrt, chemo, or trauma?

Acute post-op edema first 30 days after surgery

CAN INTERVENE DURING this time if SEVERE

typically wait 4-6 wks after surgery or XRT (can start 2 weeks after surgery)

common onset of lymphedema is 6-8 wks after XRT completed

lymphedema

Swelling usually starts most distal: lower neck, then progresses upwards into neck, jowls, etc from scar up. Over time.

Usually NOT painful if it is, seek other causes

other causes of edema

hot tub exercise allergy insect bite drug reactions thyroid function etc

Edema characteristics

Soft or Firm? Persistent or fluctuating? AM to PM, day

to day periods of resolution or exacerbation?

Garden, car, airplane, heat? Pitting vs Non-pitting? If pitting, stage it

Edema characteristics continued Visual, color? Should be approximately same as

surrounding tissue If Dark red tissue

may be angiosarcoma => lymphatic mets Physical: feverish, hot, tender

may be infection or metastasis

Pitting edema

eval based on limbs Push in gently for 5 seconds, judge how long it takes for pit to refill

Lymphedema Classifications

International Society of lymphology Lymph rating scale according to Foldi

NIH lymphedema scale

lymphedema measures Foldi Stage (0, 1, 2, 3) MDACC stage (O, 1a, 1b, 2, 3)

Foldi Stages

Stage 0 reported tightness or fullness but no

pitting or significant edema may fluctuate during the day

Stage I

Pitting edema that is quickly reversible

No fibrosis or tissue changes

Improves during the day and worsens at night

Swelling may be temporarily reduced with elevation

Stage 1

MD Anderson further differentiates: 1a: visible edema you can't pit 1b: visible edema you can pit

Stage II

Not spontaneously reversible Longer lasting pitting Fibrosis – scar-like structures within

tissues that cause them to harden Pressure may result in only slight

indentation or none No severe tissue changes, breakdown

etc

Stage III: lymphostatic elephantiasis Not typically seen in H&N Severe tissue Changes

Hyperkeratosis – increased thickness of outer layer of skin

Papillomatosis – small solid benign tumors wounds elephantiasis

Severe fibrosis Cannot pit with pressure

Facial measurements

facial circumference submental circumference horizontal neck circumference

Site of H&N Edema

Face (include eyelids, upper lip, jowl etc) Submental Neck Intra-oral Suraclavicular Fossa Unchanged from initial evalutation?

PMHx? left, right, bilateral, none now

Tactile evaluation: what do you feel? Tissue Changes? Thickness, heaviness pitting fibrosis Lumps & Bumps?

Recurrent tumor dermal mets Cyst Soft lump, lipoma (fat deposit, soft, always

ask) If ??? Notify MD

Contraindications to Lymphedema Tx Infection Cellulitis CHF Cardiac Edema Renal Failure Acute DVT Uncontrolled HTN Carotid sensitivity None Other__________

Physical appearance

Scarring trap door effect firm/rigid scar hypertrophic scar no effect

Determine

General Functional status (swallow, speech, voice, cosmesis, respiration, ROM)

Impairments related to edema vs treatment

Support system Caregivers available to assist? Home vs outpatient Cognitive status, new learning ability,

commitment?

Treatment

To justify Tx: Pt requires lymphedema Tx to soften

tissues and prevent fibrosis which may/could/can lead to dysphagia...

If pt returns Pt received Tx 'x'# months ago with 'x'

diet, now following 'x' for edema.. pt feels with edema his/her dysphagia has

increased

or in AM it’s harder to swallow

Treatment options

Manual Lymphatic Drainage (MLD) self-MLD Compression: applies external pressure

to promote improved mobilization of lymph softens firm edema and softens skin before

MLD prevents refilling of tissues and promotes

continued drainage via open pathways after MLD

Kinesiotape Deep breathing for respiratory

function/circulation swallowing routine 4x/day

Who provides the treatment? In our region: PT’s mostly YOU can be certified:

Next, closet training for Eval and Management of H&N Lymphedema is July 11-13, 2014 San Francisco

for Complete Decongestive Therapy(CDT) Certification July 5-13, 2014 Eugene, ORNorton School may offer H &N only, IF you

contact them and express interest: www.nortonschool.com

“Far and away the best prize that life offers is the chance to work hard at work worth doing.”

~Thomas Jefferson (1743-1826)

THANK YOU!

http://www.lymphnotes.com/article.php/id/208/ http://www.uspharmacist.com/content/s/172/c/29044/ http://www2.mdanderson.org/depts/oncolog/articles/13/8-aug/8-13-1.html http://www.lymphedemablog.com/2012/05/11/secondary-lymphedema-of-

the-head-and-neck/