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

Trismus  Persistent contraction of the masticatory muscles due to hypovascularity or neural damage.  Prevalence:10%-40%  “Elevator Muscles”  Temporalis  Masseter  Medial Pterygoid  Lateral pterygoid

Trismus 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.

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 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 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 mucositisWHO Grading of Oral mucositis

Mucositis Stage 1 (above) Stage 3 (below)Stage 2 (above) Stage 4 (below)

Px & Tx of Oral Mucositis  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 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

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

 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, OR Norton School may offer H &N only, IF you contact them and express interest:

“Far and away the best prize that life offers is the chance to work hard at work worth doing.” ~Thomas Jefferson ( ) THANK YOU!

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