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 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 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. 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 Stage 1 (above) Stage 3 (below) http://www.caphosol.ca/health-care-professionals 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 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 Lymphedema 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: www.nortonschool.com THANK YOU! “Far and away the best prize that life offers is the chance to work hard at work worth doing.” ~Thomas Jefferson (1743-1826) 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-andneck/