approaches to ax and tx for the slp for patients with head and neck cancer megan hyers, ms, ccc-slp...
TRANSCRIPT
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/