1. 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

2. 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)

3. 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

4. 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

5. Intervention for Dysphagia Order based on muscle effort, ease of application, ease of learning:  postures  sensory stimulation  swallow maneuvers  diet modification

6. 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

7. 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

8. Trismus http://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

9. Trismus http://oralcancerfoundation.org/dental/trismus.htm Results in:  Pain: muscle guarding  Limited oral opening: Difficulty wearing dentures Difficulty having dental work performed Difficulty with intubation for later (elective) surgeries  Dysarthria: decreased speech intelligibility  Dysphagia: difficulty swallowing/eating/drinking Reduced rotary mastication Can’t use spoon/fork, take bite of sandwich etc.

10. Trismus Therapy Stretching Systems :  Tongue blades (short stretch)  Therabite or Orastretch system (7x/day, 7reps, 7 seconds or 3x/day, 5 reps, 30 seconds)

11. 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

12. 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

13. Contraindications for Trismus  Pain  Poor dentition  Oral aperture of <10mm

14. 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.

15. 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

16. 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

17. How Development of Oral mucositisWHO Grading of Oral mucositis

18. Mucositis http://www.caphosol.ca/health-care-professionals Stage 1 (above) Stage 3 (below)Stage 2 (above) Stage 4 (below)

19. 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

20. 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

21. Treatments available  Saliva substitutes  topical and oral medications  Med Oral  Oral Balance (gel)  Mouthkote (lemon based)  Salivart (oil based)  Alcohol-free toothpaste/mouthwash (biotene)

22. 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

23. 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)

24. Pureed… again? Need variety! Protein powders Nut butters Frozen veggies Anything! What can your blender handle?

26. 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

27. The Rule of 10 Logeman, 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

28. 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

29. 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

30. Why TF?  Optimize tx tolerance  reduce complications related to poor nutrition  improve healing and recovery  increase strength and energy  enhance overall QOL  Temporary!!

31. Made it!!

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. Assessment and Treatment for the SLP Lymphedema

40.  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

42. 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

43. 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

44. 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

45. 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

46. other causes of edema  hot tub  exercise  allergy  insect bite  drug reactions  thyroid function  etc

47. 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

48. 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

49. Pitting edema  eval based on limbs  Push in gently for 5 seconds,  judge how long it takes for pit to refill

50. 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)

51. Foldi Stages  Stage 0  reported tightness or fullness but no pitting or significant edema  may fluctuate during the day

52. 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

53. Stage 1 MD Anderson further differentiates:  1a: visible edema you can't pit  1b: visible edema you can pit

54. 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

55. 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

56. Facial measurements  facial circumference  submental circumference  horizontal neck circumference

57. 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

58. 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

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

60. Physical appearance  Scarring  trap door effect  firm/rigid scar  hypertrophic scar  no effect

61. 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?

62. 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

63. 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

64. 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, OR Norton School may offer H &N only, IF you contact them and express interest: www.nortonschool.comwww.nortonschool.com

65. “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!

66.  http://www.lymphnotes.com/article.php/id/208/ http://www.lymphnotes.com/article.php/id/208/  http://www.uspharmacist.com/content/s/172/c/29044/ http://www.uspharmacist.com/content/s/172/c/29044/  http://www2.mdanderson.org/depts/oncolog/articles/13/8-aug/8-13-1.html 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/