After-care, Rehabilitation and
Follow-up
Professor Magdy Amin RIAD
Professor of Otolaryngology.
Ain shames University
Senior Lecturer in Otolaryngology
University of Dundee
cancers of the upper aerodigestive
tract
• Post treatment major dysfunction with airway,
eating and drinking.
• Patients with tracheostomy.
• Patients with surgical voice restoration prosthesis.
• Dental problems, dry mouth, and oral postradiotherapy dysfunction.
• Neck and shoulder problems.
• Return to work
The main aims of follow-up include:
1. Identification of recurrent tumour or new
primary disease.
2. Provision of help for patients suffering from
side-effects of treatment (particularly delayed
effects of radiotherapy).
3. Identification of patients who need additional
help with functional or psychosocial
problems.
Structure of services
• The structure of support and rehabilitation
services for patients who have been treated for
head and neck cancers should be reviewed at
Specialised Cancer clinic level.
• written rehabilitation plan.
• Specialised Support Team should ensure that
the long-term needs of patients and carers are
met.
Local Support Team Members
• ENT/maxillofacial surgeon.
• Regular examination of the neck is
particularly important during the first two
years after treatment, when 90% of
recurrences develop.
Local Support Team Members
• Nurse practitioner, who can provide
advanced skills for the management of
stomas (tracheostomies and gastrostomies),
nasogastric tubes and tracheoesophegal
valves.
Local Support Team Members
• Speech and language therapist (SALT):
Voice
Swallowing
• Dietician
• Dental hygienist
Local Support Team Members
• Psycho-oncology, liaison psychiatry or
clinical psychology services
• Local patients who are willing to provide
‘buddy’ support.
• Physiotherapist
• Occupational therapist
• Social worker
Follow-up
• patients who continue to smoke or drink
alcohol should be encouraged to take up
interventions to help them quit.
• Follow-up after radiotherapy should include
assessment of dental health, the lining of the
mouth and salivation, since adverse effects
in these areas are common and usually
treatable.
Oral and dental care
• Specialist restorative dentistry and
prosthodontic expertise should be available.
• A trial of pilocarpine should be offered to
patients with persistent xerostomia (dry
mouth) after radiotherapy who had normal
salivary function before treatment.
Swallowing rehabilitation
• Swallowing rehabilitation for patients dependent
on tube feeding after treatment for head and neck
cancer usually takes about three months,
according to a Dutch study.
• although about 20% need help for six months or
more and some patients (9 of a group of 82) did
not respond to therapy.
• Patients with transport problems fared better than
those with aspiration.
OTHER CONDITIONS
• 11% no definite diagnosis.
• Globus and GERD not included.
POST OP
MYOPATHIES
CRANIAL NV
POUCHES
MECHANISM OF SWALLOWING
several closely coordinated actions are involved:
(1) elevation and retraction of the soft palate with closure of
the nasopharynx,
(2) UES opening,
(3) laryngeal closure at the level of the laryngeal vestibule,
(4) tongue loading
(5) tongue pulsion
(6) pharyngeal clearance.
These events occur in close synchrony, and last only one
second.
Normal oropharyngeal swallowing
The sensory cues that elicit pharyngeal swallowing are not precisely
known.
sensory receptive field of the superior laryngeal nerve seems to be
the crucial stimulus.
swallowing can also be initiated solely by volitional effort if there is
food or fluid within the oral cavity.
Deglutitive pharyngeal reconfiguration:
Laryngeal vestibule closure
• A fundamental aspect is transforming the oropharynx from a
respiratory to a swallowing pathway .
• By opening the inlet to the esophagus and sealing the inlet to the
larynx.
• Laryngeal vestibule closure, is achieved by laryngeal elevation
and anterior tilting of the arytenoid cartilages against the base of
the epiglottis.
• Laryngeal elevation is quantifiable fluoroscopically
Deglutitive pharyngeal reconfiguration:
UES relaxation
• Videofluoroscopic studies done concurrently with manometry have shown that
UES relaxation occurs during laryngeal elevation .
• Relaxation of the sphincter precedes opening by approximately 0.1 seconds.
• UES opening results from anterior traction caused by contraction of the
suprahyoid and infrahyoid musculature.
Deglutitive pharyngeal reconfiguration :
UES opening
Clinically, this is a significant point in that :
impaired UES opening can result from either impaired traction on the
sphincter or impaired sphincter relaxation.
• Impaired traction should be evident fluoroscopically by diminished
anterior hyoid displacement.
• impaired relaxation is only detectable manometrically
pharyngeal swallowing:
propulsive phase of tongue
• The functional elements of pharyngeal swallowing
are the propulsive phase of tongue action and of
propagated contraction of the pharyngeal
constrictors.
• Bolus propulsion relies heavily on deglutitive
tongue action, transpiring between times 0.00 and
0.13
pharyngeal swallowing:
pharyngeal contraction
• the propagated pharyngeal contraction progresses from the superior to
middle to inferior pharyngeal constrictors at approximately 15 cm/s.
•
Stripping almost all residue from the pharynx and hypopharynx except
for trace amounts that may be left in the valleculae or pyriform sinuses.
• Thereby minimizing the chance that aspiration will occur with resumed
respiration.
Resumption of respiration
• After bolus clearance, the process of pharyngeal reconfiguration is
reversed.
• Allowing resumption of respiration.
• The entire pharyngeal swallow occurs in approximately 1 second
Oropharyngeal dysphagia
Major categories of dysfunction are
(1) Inability or excessive delay in initiation of pharyngeal
swallowing.
(2) Aspiration.
(3) Nasopharyngeal regurgitation.
(4) Residue within the pharyngeal cavity after swallowing.
five fundamental questions
• Does the patient describe dysphagia as opposed to
globus sensation or Xerostomia?
• Is the dysphagia oropharyngeal or esophageal in
origin?
• Is the dysphagia caused by a structural or functional
disorder?
• How severe is the dysphagia and are complications
present?
• Is there an underlying related or causative disease?
Xerostomia
common in the elderly,
present in 16% of men and 25% of women.
Dysphagia is attributed to loss of the moistening and
lubricating qualities of saliva.
Dry mouth may be accompanied by dry eyes, inflammatory
arthropathy (Sjogren’s)
History of head and neck radiotherapy, or concurrent
medications with anticholinergic side effects.
Detailed drug history is also important because a number of
centrally acting drugs can impair oropharyngeal function
Videofluoroscopic evaluation of oral
and pharyngeal function
(Gold standard)
(1) inability or excessive delay in initiation of
pharyngeal swallowing,
(2) Aspiration
(3) Nasopharyngeal regurgitation
(4) Residue within the pharyngeal cavity after
swallowing.
Videofluoroscopy:
Limitations
videofluoroscopy does not allow:
1.Quantification of pharyngeal contractile forces.
2.Detection of incomplete UES relaxation
(which can occur despite normal opening),
3.Quantification of the magnitude of intrabolus
pressure during swallowing
Nasoendoscopy:
FEES
• Optimal method for identification of
intracavitary structural lesions .
• identification and biopsy of mucosal
abnormalities.
• Liquids and foods colored with food dye
are traced during swallowing
inability or excessive delay in initiation of
pharyngeal swallowing and
Speech Rehabilitation
• A recent US study indicated that 27% of patients
used oesophageal speech, 21% used
tracheosophageal speech, and 48% used an
electrolarynx.
• 89% of patients in the two former groups were
satisfied with their means of communication, but
satisfaction levels were lower (62%) among those
who used the electrolarynx.
Repositioning of VF
• Secure airway.
• Prevent aspiration.
• Voice quality.
Arytenoidectomyposterior cordotomy
• 3 to 4 mm posterior
glottic chink.
• Mild to moderate
exercise.
• If in doubt keep the
tracheotomy.
VF Medialisation
VF injection
•
•
•
•
Timing.
Material.
Amount.
Route.
Thyroplasty
• Reversible.
• Local anaesthesia.
• Avoid laryngeal
scarring.
• Posterior glottic
competency.
• Manipulation of
acoustic properties.
Laryngeal position alteration
Alaryngeal voice
Alaryngeal voice
TE surgical set
TE puncture
TE tract
TE Prosthesis
Speech Rehabilitation
• An older study, also from the US, reported that
speech therapy after laryngectomy took an average
of five months in patients assessed before surgery,
and three months for those reviewed after surgery.
• 26% of prospectively studied patients used
oesophageal speech as the dominant mode of
communication, 34% the electrolarynx and 34%
communicated by writing.
• 45% were considered not to be successfully
rehabilitated.
Speech Rehabilitation
• Patients with problems that make rehabilitation
more difficult such as :
hearing impairment,
previous neurological,
pulmonary and
gastroenterological disease
• can be identified before treatment.
• These patients require intensive help
Restorative dentistry
• Dental and facial bone restoration using
osseointegrated implants are effective for
many patients, despite radiation damage to the
jawbone.
• The proportion of implants reported lost over
five years varies between 22% to 79% in
patients who have been treated with
radiotherapy.
Restorative dentistry
• One study suggests that hyperbaric oxygen
may improve osseointegration in irradiated
patients.
• The probability of success appears to be
higher when reconstruction is carried out
more than four months after implantation.
• Loss rates are below 20% in patients who
have not been irradiated.
Treatment for persistent
xerostomia
• pilocarpine can be effective for patients with
xerostomia after radical radiotherapy to the head
and neck.
• Adverse events are dose-related; increased
sweating, for example, occurs in about a quarter of
those taking 5mg three times daily, and in twice as
many taking twice this dose.
• No severe or life-threatening events were reported
in any study.
Treatment for persistent
xerostomia
• One review concluded that the optimum
dose is 5mg three times a day.
• But it is not clear whether systemic or
topical pilocarpine is more effective.
incidence of recurrent disease and
additional primary tumours
• 30-50% of patients had local or regional
recurrences within five years of initial treatment
for head and neck cancer.
• the risk of developing a second cancer (most often
in the head and neck, oesophagus or lung) among
these patients is 10 to 30 times that in the general
population.
• Continued smoking and drinking after initial
treatment are both associated with significant
increases in risk.
Palliation
• as many as half of all patients who develop head
and neck cancers eventually die of the disease and
will require palliative interventions.
• Many experience moderate to severe pain, which
should be regularly assessed and treated in
accordance with the WHO analgesic ladder.
• In most cases, the cause of death is tumour in the
head and neck.
• Choking or bleeding to death is particularly feared