Dysphagia and Dysphonia following Organ Preservation for Head

1
Dysphagia and Dysphonia following Organ
Preservation for Head Neck Cancer Treatment

• ASHA Convention
• Boston, 2007
• Donna Tippett, Heather Starmer, Kim Webster
• Johns Hopkins University
• Department of Otolaryngology, Head Neck Surgery

2
Outline

• Introduction to organ preservation
• Oral motor exercises and dysphagia
• Related toxicities
• Trismus
• Xerostomia
• Dysphonia
• Quality of Life
• Summary, questions answers

3
Learner objectives

• Demonstrate understanding of functional impact of
  organ preservation approaches on swallowing and
  voice
• Discuss the impact of toxicities on swallowing
  and voice
• Describe therapeutic interventions that may be
  beneficial
• Discuss current literature influencing clinical
  decision making

4
Terminology

• Organ preservation
• Organ conservation
• Primary radiotherapy
• Chemoradiation
• Induction chemotherapy
• Adjuvant chemo-/radiotherapy
• Neoadjuvant
• Combined modality
• Clinical trials and protocols

5
Functional Outcomes and HN Cancer

• Treatment modality
• Locus of tumor
• Other factors

6
Patient Factors

• Age
• Gender
• Culture
• Family support
• Previous swallowing problems
• Motivation

• Geographic location
• Other health history
• Occupation
• Complications
• Prioritizing
• Quality of life

7
Sticking
Pain
No appetite
Trismus
Nausea
Vomitting
Dry throat
Fear
Mucositis
No taste or smell
Choking
Dry mouth
Swelling
Fistula
No energy
Fatigue
Stitches
8
Other Considerations

• Tracheostomy tubes
• Can reduce laryngeal elevation
• Irritation of airway
• Can reduce laryngeal sensation
• Occlude for swallow
• Window

• Feeding tubes
• Reduce anxiety
• Allows for learning
• Greater energy
• Maximize nutrition

9
Predicting Dysphagia from Tx RADIATION THERAPY
may cause

• Mucositis
• Xerostomia
• Edema
• Trismus
• Dental caries
• Candida

• Altered smell and taste
• Reduced appetite
• Fibrosis
• Osteoradionecrosis
• Odynophagia

10
Swallowing post XRT

• Oropharyngeal Symptoms
• Reduced soft palate elevation
• Reduced swallow initiation
• Reduced BOT retraction
• Thickened immobile epiglottis
• Reduced laryngeal elevation
• Reduced airway protection
• Reduced pharyngeal contraction
• Reduced cricopharyngeal opening
• Stricture(s)
• Webs

11
Predicting Dysphagia from Tx

• Chemotherapy/Organ Preservation
• Nausea
• Oral mucositis
• Fatigue
• Other side effects from radiation ?d
• Longer recovery from effects
• Preservation of organ ? preserved function

12
Predicting Dysphonia from Tx RADIATION THERAPY
may cause

• Fibrosis
• Xerostomia
• Edema
• Mucositis
• Atrophy

• Decreased pliability of the vocal folds
• Reduced glottic closure
• Impaired vibration of the mucosal surface
• Reduced amplitude of vibratory excursion
• Supraglottic compensation

13
Voice post XRT

• Voice symptoms
• Reduced pitch variability
• Reduced loudness
• Reduced phrase length
• Hoarse or breathy vocal quality
• Vocal strain
• Vocal fatigue
• Reduced ability to sing

14
Dysphagia Treatment at JH

• Before organ preservation therapy
• Educate
• Exercise
• Evaluate
• During
• Make behavioral accommodations, modifications
• Review exercises, should be done daily if
  possible
• Monitor/Evaluate
• After
• Evaluate changes occur up to 15 years later
• Continue home exercises for a minimum of 4-6
  weeks after tx
• Initiate formal dysphagia tx as indicated

15
Dysphonia Treatment at JH

• Before organ preservation therapy
• Educate
• Exercise
• Evaluate
• During
• Make behavioral accommodations, modifications
• Review exercises, should be done daily if
  possible
• Monitor/Evaluate
• After
• Evaluate as needed
• Continue prophylactic exercises for at least 4-6
  weeks after tx
• Implement formal intervention if necessary

16
Pre-treatment Information

• Reduces anxiety
• Improves post-treatment compliance
• Involves the patient as a team member
• Better post-tx speech targets
• Assess writing, legibility, socio- and
  occupational communication needs

Lazarus, 2005 Glaze, L. 2005
17
Medical/Surgical Tx for Dysphagia/Dysphonia

• Vocal fold medialization by injection
• Dilatation
• Surgery
• Cricopharyngeal myotomy/Botox
• Soft tissue augmentation (tongue base)
• Oral prosthetics
• Supraglottic/glottic closure
• Medialization thyroplasy
• Laryngotracheal separation (LTS)
• Total laryngectomy
• Rerouting salivary ducts
• Dennervation of salivary glands

18
Dysphagia
19
Organ Preservation Approachesand Dysphagia

• Nature of dysphagia after organ preservation tx
• Recovery of swallowing function
• Swallowing intervention

20
Characteristics of Dysphagia

• Goguen et al, 2006
• Prospective cohort study
• N 23 s/p CRT for head/neck SCCA
• Common deficits
• Decreased epiglottic tilt
• Decreased BOT retraction
• Decreased laryngeal elevation
• Impaired bolus propulsion
• Laryngeal penetration/aspiration
• 14/23 pharyngoesophageal narrowing

21
Characteristics of Dysphagia

• Dworkin et al, Dysphagia, 2006
• Retrospective study
• Performed FEES in individuals with Stage III/IV
  laryngeal SCCA
• Multiple decompensations
• Excess oropharyngeal secretions
• Premature spillage into vallecula
• Retention in vallecula
• Post cricoid residue
• Laryngeal penetration/aspiration

22
Characteristics of Dysphagia

• Logemann et al, Head Neck, 2006
• Examined differences in swallowing across tumor
  sites and CRT protocols
• VFSS pre- and 3 months post tx
• N 53 with Stage III/IV head/neck SCCA
• Common deficits
• Reduced BOT retraction
• Reduced tongue strength
• Delayed laryngeal vestibule closure

23
Characteristics of Dysphagia

• Pauloski et al, Head Neck, 2006
• Prospective cohort study
• VFSS pre- and post tx
• N 170 with head/neck SCCA
• Identified multiple decompensations
• Limitations in oral intake and diet post tx were
  significantly related to
• Reduced laryngeal elevation
• Reduced CP opening
• Rating of nonfunctional swallow on at least 1
  bolus type

24
Recovery

• Goguen et al, Otolaryngol Head Neck Surg, 2006
• Prospective cohort study
• F/u at 3, 6, 9, 12, 24 months post tx
• N 59
• Primary tumor sites oral cavity, oropharynx,
  hypopharynx, larynx

25
Recovery

• Goguen et al, 2006

26
Recovery

• Dworkin et al, Dysphagia, 2006
• N 14 with Stage III/IV laryngeal SCCA
• lt12 months 43 regular/near normal diet
• gt12 months 86 regular/near normal diet

27
Recovery

• Pauloski et al, 2006

28
Dysphagia Therapy
29
Dysphagia Therapy

• Targets
• BOT retraction
• Tongue strength
• Laryngeal elevation
• Goguen et al, 2006
• Logemann et al, 2006
• Pauloski et al, 2006

30
EBP

• Internal source of information
• Best clinical judgment
• Knowledge of anatomy/physiology
• External source of information
• Electronic database search
• PubMed Clinical Queries
• Coyle J Leslie P, Perspectives on Swallowing
• and Swallowing Disorders, 2006

31
Exercise Principles

• Goal selection
• Specificity of training
• Overload/progression
• Clark H, AJSLP, 2003

32
Exercise Principles

• Goal selection
• Specificity of training
• Overload/progression
• Clark H, AJSLP , 2003

33
Exercise Principles

• Goal selection
• Specificity of training
• Overload/progression
• Clark H, AJSLP , 2003

34
Theoretically Sound Exercise

• Mendelsohn maneuver
• Addresses goals for
• Stretching maintaining maximum laryngeal
  elevation over several seconds
• Strengthening sustaining laryngeal elevation
  against resistance
• Meets criteria for specificity and progression
• Clark H, AJSLP , 2003

35
Theoretically Sound?

• Tongue resistance exercise
• Involves an isometric, static contraction
• Address strengthening
• May meet the criteria for progression
• Does not meet criteria for specificity

36
Swallowing Maneuvers

• Supraglottic, super-supraglottic, tongue-hold,
  effortful swallow, and Mendelsohn
• Increased laryngeal elevation and laryngeal
  vestibule closure with maneuvers
• Improved airway protection
• Tongue base-pharyngeal wall pressures and contact
  duration increased with maneuvers
• Lazarus et al, Head Neck,1994
• Logemann et al, Head Neck, 1997
• Lazarus et al, Folia Phoniatri Logopaed, 2002

37
Theoretically Sound?

• Voluntary swallow maneuvers
• May address strengthening and/or stretching
• May meet the criterion for progression
• Meet the criterion for specificity

38
Swallowing Intervention

• Kulbersh et al, Laryngoscope, 2006
• Cross sectional analysis of QOL to determine
  efficacy of pre-tx intervention
• Administered MDADI
• N 25 pre tx swallowing exercises
• N 12 post tx swallowing exercises

39
Swallowing Intervention

• Kulbersh et al, 2006
• Adjusted Mean Scores on MDADI

40
Efficacious Approach

• Need to determine what you are targeting
• Specify the rationale for tx
• Match the exercise as closely as possible to the
  desired outcome
• Try exercises at baseline
• Document changes in fx, QOL, weight

41
Related ToxicitiesTrismus and Xerostomia
42
Trismus

• Dijkstra et al , Oral Oncol, 2004
• Prevalence 5 - 38 in head/neck cancer
• Variation secondary to lack of uniform criteria,
  visual assessment, retrospective review

43
Criteria for Trismus

• Normal MIO 467mm
• Steelman et al, Mo Dent J, 1986
• MIO lt 30 35mm
• Buchbinder et al, J Oral Maxillofac Surg, 1993
  Dijkstra et al, J Oral Maxillofac Surg, 2006

44
Treatment for Trismus

• Buchbinder et al, J Oral Maxillofac Surg, 1993
• N 21 s/p resection of oral SCCA and radiation
  tx lt5 years

45
Treatment for Trismus

• Cohen et al, Arch Phys Med Rehab, 2005
• N 7 s/p surgery for oropharyngeal SCCA

p lt .01
46
Treatment for Trismus

• Dijkstra et al, Oral Oncology, 2007
• Retrospective study
• N 27 patients with trismus secondary to
  head/neck SCCA and 8 with trismus secondary to
  other dx
• Treatment included
• Active ROM
• Hold relax techniques
• Manual stretching
• Joint distraction
• Use of devices and tools

47
Treatment for Trismus

• Dijkstra et al, 2007

p lt .05
48
Oral Health

• Xerostomia
• Relationship between oral hygiene and aspiration
• Oral cancer self-examination

49
XerostomiaVisual Inspection of the Mouth

• Tongue depressor sticks to buccal mucosa
• Lipstick sign
• Dry, sticky or erythematous oral mucosa
• Red patches on palate, tongue
• Decreased lingual papillae
• Little pooled saliva in FOM
• Stringy, ropy, foamy saliva

50
Xerostomia Visual Inspection of the Mouth
51
When residual glandfunction remains

• Can recommend
• Fresh, light acidic fruits
• Slices of cold cucumber, tomato, melon, apple
• Sour tasting, sugarless candy
• Chewing gum
• Vitamin C tablets per MD approval
• Encourage routine and professional dental care

52
When saliva productioncannot be stimulated

• Can recommend
• Frequent sips of water
• Saline mouth rinse
• Oral lubricants
• Glycerin (may irritate oral mucosa)
• Room humidifier
• Criswell et al, Laryngoscope, 2001 Vapotherm
  MT-3000

53
When saliva productioncannot be stimulated

• Can recommend changes in diet to avoid damage to
  fragile mucosa
• Avoid dry, spicy foods
• Avoid temperature extremes
• Avoid alcohol, tobacco, caffeine, sugar
  containing products
• Encourage routine and professional dental care

54
When saliva productioncannot be stimulated

• Momm et al, Strahlentherapie und Onkologie, 2005
• Crossover study comparing four saliva substitutes
• Best treatment was very individual
• Recommend that patients try different agents to
  identify what works best for them

55
When saliva productioncannot be stimulated

• Biotene and Oralbalance
• Contain salivary enzymes to suppress microbial
  colonization, inflammation
• Decreased oral dryness (Regelink et al,
  Quintessence Int, 1998 Warde et al, Support Care
  Cancer, 2000)
• No antimicrobial action limited dwell time
  (Epstein et al, Oral Oncology,1999)

56
Oral Hygiene

• Ignore your teeth and theyll go away.

57
Oral Hygiene

• Terpenning et al, J Am Geriatr Soc, 2001
• But potential respiratory tract pathogens will
  still colonize in saliva, and on oral mucosa and
  denture surfaces
• S. aureus and S. sobrinus in saliva

58
Oral Care as Treatment

• Pneumonia, febrile days and death from pneumonia
  significantly decreased in patients with oral
  care than those without oral care
• Adachi et al, Oral Surg Oral Med Oral Pathol Oral
  Radiol
• Endod, 2002
• Yoneyama et al, J Am Geriatr Soc, 2002

59
Need for More Data

• Effectiveness of oral hygiene programs in
  reducing aspiration pneumonia seems
  promisingneed more high level evidence
• Terpenning, Aging Infect Dis, 2005
• Loeb et al, J Am Geriatr Soc, 2003

60
Oral CancerSelf-Examination

• NCI Surveillance, Epidemiology, End Results, 2001
• 30 of oral cancers originate on tongue
• 17 in lip
• 14 in floor of mouth
• Resources
• National Institute of Dental and Craniofacial
  Research
• oralcancerfoundation.org
• oral-cancer.org

61
Dysphonia
62
Organ Preservation Approachesand Dysphonia

• Voice characteristics after organ preservation
  treatment
• Vocal hygiene and xerostomia
• Voice therapy

63
Common complaints after organ preservation
approaches

• Reduced pitch variability
• Reduced ability to sing
• Reduced loudness
• Reduced phrase length
• Hoarse or breathy vocal quality
• Vocal strain
• Vocal fatigue

64
Organ Preservation Approachesand Dysphonia

• Videostroboscopic findings
• Increased supraglottic tension
• Pooling of thick secretions
• Impaired mobility
• Glottic incompetence
• Irregularity of leading edge of vocal fold
• Asymmetry and inadequate amplitude and mucosal
  wave
• Fung et al, Journal of Otolaryngology, 2001
• Meleca et al, Laryngoscope, 2003

65
Videostroboscopic findings
66
Organ Preservation Approachesand Dysphonia

• Voice Handicap Index findings
• 27 reported significant handicap
• Self-perceived handicap greater in younger
  individuals
• Handicap increased as a function of time
  post-treatment
• Fung et al, Journal of Otolaryngology, 2001
• Meleca et al, Laryngoscope, 2003

67
Organ Preservation Approachesand Dysphonia

• Acoustic/aerodynamic findings
• Lower fundamental frequency for females
• Elevated jitter and shimmer
• Reduced MPT
• Elevated subglottic pressure and glottal
  resistance
• Fung et al, Journal of Otolaryngology, 2001
• Meleca et al, Laryngoscope, 2003

68
Organ Preservation Approachesand Dysphonia

• Mlynarek, Kost, Gesser, Journal of
  Otolaryngology, 2006
• Patients with better videostroboscopic findings
  after radiation alone
• Patients with better VHI and acoustic measures
  after surgery

69
Organ Preservation Approachesand Dysphonia

• Voice outcomes slightly better after radiation
  versus surgery for early glottic lesions
• Simpson et al, Otolaryngologic Clinics of North
  America, 1997
• Jones et al, Head and Neck, 2004
• Krengli et al, Acta Oncologica, 2004
• Voice related quality of life comparable between
  radiation and surgery for early glottic lesions
• Cohen et al, Annals of Otology, Rhinology, and
  Laryngology, 2006
• Peeters et al, Laryngology, 2004

70
Xerostomia and Voice

• Roh et al. Journal of Clinical Oncology 2005.
• Wide field radiation had greatest impact on
  salivary flow (four fold difference)
• Increased voice disturbance (elevated but not
  significant)
• Increased abnormalities under videostroboscopy
  (supraglottic activity, dryness of vocal folds,
  stickiness of secretions)
• Reduced voice related quality of life (moderate
  or greater impairment on VHI)

71
Voice Therapy

• Improve vocal hygiene
• Improve glottic valving
• Balance respiratory, phonatory, and resonant
  systems
• Improve pliability and pitch variability
• Reduce supraglottic constriction
• Compensate

72
Voice Intervention

• vanGogh et al, Cancer, 2006
• Efficacy of voice therapy following treatment for
  laryngeal cancer
• Findings
• Voice Handicap Index
• Average improvement of 15 points post-treatment
• Acoustic parameters
• Improvement in NHR and jitter post-treatment
• Subjective reduction in perception of vocal fry

73
Hydration and Voice

• Improving hydration may
• Reduce phonation threshold pressure
• Reduce patient perceived vocal effort
• Improve vocal quality
• Solomon and DiMattia, Journal of Voice, 2000
• Verdolini et al, Journal of Speech and Hearing
  Research, 1994
• Yiu and Chan, Journal of Voice, 2003

74
Vocal Function Exercises (VFE)

• Holistic approach targeting balance of airflow,
  laryngeal musculature, and the resonant tract
• Uses specifically trained postures for sustained
  phonation and pitch variation to improve balance
  of three subsystems
• Described by Stemple in Seminars in Speech and
  Language 2005.

75
Should VFE be beneficial following organ
preservation?

• Voice problems after organ preservation
• Reduced pitch variability
• Reduced loudness
• Reduced phrase length
• Hoarse or breathy vocal quality
• Vocal strain
• Vocal fatigue
• Reduced ability to sing

• 1, 7. Pitch manipulation (stretching/contracting
  ) should help to improve pliability
• 2, 3, 4, 6. Studies are supportive of improved
  glottic valving after use of VFE
• 5, 6. Use of forward focused phonation should
  unload supraglottic constriction

76
Vocal Function Exercise (VFE) Validation

• Stemple et al, Journal of Voice, 1994
• Randomized, double-blind placebo controlled study
• Evaluated effects of 4 weeks of VFE in normal
  voice users
• Post-treatment assessment revealed
• Increased phonation volume
• Decreased airflow rate
• Increased maximum phonation time
• Improved frequency range
• No changes noted in the placebo or control groups

77
Vocal Function Exercise (VFE) Validation

• Sabol et al, Journal of Voice, 1995.
• Evaluated the impact of VFE on sophisticated
  voice users (opera singers)
• 4 week treatment period
• Post-treatment testing revealed
• Increased phonation volume
• Decreased airflow rate
• Increased maximum phonation time
• No change in control group

78
Vocal Function Exercise (VFE) Validation

• Roy et al, Journal of Speech, Language, and
  Hearing Research, 2001.
• A prospective, randomized clinical trial
  comparing effects of VFE versus vocal hygiene
  alone
• 6 week treatment period
• Group receiving VFE reported an improvement in
  voice handicap using the VHI
• Vocal hygiene group reported no change
• Control group reported decline in VHI scores
  after 6 week period

79
Resonant Voice Therapy (RVT)

• Holistic approach incorporating focus on
  resonance in order to balance subsystems
  (respiration, phonation, resonance)
• One variant described by Verdolini, 1998
  Lessac-Madsen Resonant Voice Therapy (LMRVT)

80
Should RVT be beneficial following organ
preservation?

• Voice problems after organ preservation
• Reduced pitch variability
• Reduced loudness
• Reduced phrase length
• Hoarse or breathy vocal quality
• Vocal strain
• Vocal fatigue
• Reduced ability to sing

• 2, 3, 4, 5, 6. Improving glottic closure should
  improve all these parameters
• 1, 7. Pitch manipulation (stretching/contracting)
  should help to improve pliability
• 5, 6. Use of forward focus should reduce
  supraglottic strain

81
Resonant Voice Therapy (RVT) Validation

• Chen et al, Journal of Voice, 2007.
• Evaluated the impact of RVT on teachers with
  voice complaints (adaptation of LMRVT)
• 8 week treatment period
• Measures included
• auditory perceptual judgment
• videostroboscopic examination
• acoustic measurements
• aerodynamic measurements
• functional measurements

82
Resonant Voice Therapy (RVT) Validation

• Chen et al, Journal of Voice, 2007.
• Perceptual findings
• Improvement in roughness, strain, monotone,
  resonance, hard attack, glottal fry, and vocal
  fatigue
• Stroboscopic findings
• Improvement in glottic closure, mucosal wave,
  amplitude, and vocal pathology
• Acoustic findings
• Range of frequency and intensity improved
• Aerodynamic findings
• Phonation threshold pressure reduced
• Functional findings
• Significant reduction in physical subscale of VHI

83
Circumlaryngeal Massage

• Manual tension reduction technique
• Includes clinician reposturing of the larynx
  during voice use
• Compression in the a/p plane (push back)
• Reduction in laryngeal elevation (pull down)
• Combination of medial compression and traction
• Circular massage over the hyoid, thyrohyoid
  space, posterior thyroid, suprahyoid muscles

84
Circumlaryngeal Massage Validation

• Multiple studies validate use of manual tension
  reduction for hyperfunctional voice users
• Roy Leeper, Journal of Voice, 1993
• Roy et al, Journal of Voice, 1997

85
In conclusion

• Patients will often report voice changes after
  organ preservation approaches
• Patient perceived handicap may be higher than
  expected based on acoustic voice properties
• Voice therapy should be effective But we still
  need more data

86
Quality of Life After Treatment for Head and Neck
Cancer
87
Cooperative Care

• Mclane et al, 2003
• New tx model, teaches pt and care partner in
  homelike setting
• Facilitated autonomy, communication and role
  resumption reduced anxiety

88
Multidisciplinary Care

• Blair Callender, 1994
• Collaboration and communication of
  multidisciplinary teams have had a profound
  effect on the treatment of head and neck cancer
• Essential for positive outcomes

89
QOL and Coping

• Pourel et al, 2002
• The level of symptoms and functioning was similar
  regardless of treatment modality
• In long-term survivors of oropharynx ca, coping
  processes are most important

90
Multidisciplinary Clinicsand Patient Satisfaction

• Walker et al, 2003
• Overall satisfaction predicted by younger age,
  female gender and greater attention to how
  patients were coping with illness.

91
Supports

• For inherent functional deficits
• To local, national groups
• International Association of Laryngectomees
• Support for People with Oral and Head Neck
  Cancer (SPOHNC)
• Other head and neck cancer support groups

92
Received vs. Available Support

• De Leeuw et al, 2000
• Available support is beneficial regardless of
  situation
• Effect of received support was equivocal

93
Psychological Distress

• Hutton Williams, 2001
• -Trend for depression to decrease with time and
  to be less common among those attending a support
  group

94
UW-QOL Organ Preservation
Deleyiannis FW et al. Head Neck, 1997
95
Factors Associated with Worse QOL

• Feeding tube
• Tracheostomy tube
• Chemotherapy
• Neck dissection

• Depression
• Multiple comorbidities
• Tumor stage
• Age

• Terrell JE et al Arch Otolaryngol Head Neck
  Surg, 2004
• Karnell LH et al. Head Neck, 2006
• Gourin CG et al. Laryngoscope 2005

96
Are QOL assessments accurate measures of function?

• Post-treatment QOL improves over time- even in
  face of functional deficits
• Expectations affect QOL
• Reports are biased what about
• Non-survivors
• Non-responders
• Does their QOL differ?

97
Summary
98
Radiation Therapy and SLP

• Involvement of speech pathologists in evaluation
  and treatment of patients with dysphagia can
  minimize swallowing difficulties and identify the
  tissues most responsible for swallowing.
  Minimizing radiation dose to these tissues may
  lower the incidence of radiation-induced
  dysphagia

Garden et. al, 2006
99
Radiation Therapy and Nutrition

• Eating problems were common before treatment
  started, and at the end of radiotherapy every
  patient suffered from eating problems. One year
  after treatment the majority still had eating
  problems

Larsson et. al, 2005
100
SLP Role in Organ Preservation for Head and Neck
Cancers

• Education
• Exercises
• Connections
• Support
• Swallowing

• Voice
• Speech
• Oral Health
• Research
• Functional Outcomes

101
Conclusions
102
Organ Preservation ?Functional Preservation

• Treatment related functional impairments
• Importance of speech-language pathology services
• Management at Johns Hopkins
• Current evidence