Treatment Protocols for Individuals Undergoing

Organ Preservation Treatment

Heather Starmer, M.S., CCC-SLP1

Donna C. Tippett, M.P.H., M.A., CCC-SLP1,2

Department of Otolaryngology—Head and Neck Surgery1

Department of Physical Medicine and Rehabilitation2

Johns Hopkins University

Learner objectives

• Explain treatment protocol from pre- to post-treatment

• Describe therapeutic interventions that may be beneficial

• Discuss current literature influencing clinical decision making

Multidisciplinary assessmentPre-treatment SLP consultationVoice

Swallowing Clinical controversies

Multidisciplinary Assessment

• Surgical oncology• Radiation oncology• Medical oncology• Speech-language pathology• Nursing• Social work• Dietary• Research coordinator• Clinical care coordinator

Multidisciplinary Care

• 2008 Practice guidelines consider multidisciplinary care as standard of care for head and neck cancer patients– NCCN (National Comprehensive Cancer Network)– ESMO (European Society of Medical Oncology)– AHNS (American Head and Neck Society)

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”

Potential Benefits of Multidisciplinary Assessment

• Westin & Stalfords, 2008– Built in second opinion for treatment planning– Education– Increased consideration of ethics and QOL– Cost efficiency– Coordination of care– Improved patient outcomes

Additional Benefits of Multidisciplinary Approach

• Increased recruitment for research (McNair et al, 2008)

• Fewer missed visits (Dwyer et al, 2008; Kremp et al, 2008)

Tumor Board Conferences

• Weekly

• Confirm diagnosis and stage

• Treatment planning

• Referrals

• Multidisciplinary

Tumor Board Conferences

• Head and neck surgeons• Medical oncologists• Radiation oncologists• Oral pathologists• Oncology nurses• Otolaryngology nurses

• Speech-language pathologists

• Dental prosthodontists• Nuclear medicine

radiologists• Social workers• Dieticians

Multidisciplinary assessmentPre-treatment SLP consultationVoiceSwallowingClinical controversies

Roles of theSpeech-Language Pathologist

• Evaluation• Education• Exercises• Connections• Support• Swallowing

• Voice• Speech• Oral Health• Research• Functional

Outcomes

Pre-treatment Evaluation

• Clinical evaluation– Maximum jaw opening– Oral hygiene

• Instrumental evaluation of swallowing– Videofluoroscopic assessment (VFSS)– Fiberoptic endoscopic evaluation (FEES)

• Voice– Videostroboscopy– Acoustic/aerodynamic assessment

• Quality of life• Patient and support analysis

Pre-treatment Consultation• Education re: expected changes

– Speech/voice– Swallowing– Oral health

• Review VFSS/FEES– Diet modifications– Compensatory strategies

• Pre-treatment swallowing exercises• Jaw ROM• Referrals

Pre-treatment Information

• Reduces anxiety• Improves post-treatment compliance• Involves the patient as a team member• Better post-tx speech targets

Lazarus, 2005; Glaze, 2005

Pre-treatment Swallowing Exercises

• Lingual resistance• Straw resistance• Mendelsohn maneuver• Masako maneuver

• Effortful swallow• “Sirening” technique• Jaw range of motion

Pre-treatment Swallowing Exercises

• 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

Pre-treatment Swallowing Exercises

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

Domain Pre Tx Post Tx

Global 74.4 32.9

Emotional 72.1 53.9

Functional 68.7 58.6

Physical 66.4 43.2

Pre-treatment Swallowing Exercises

• Carroll et al, Laryngoscope, 2008– Retrospective analysis of outcomes of 18

patients • 9 patients initiated tx 2 weeks prior to XRT• 9 patients initiated tx after completion of XRT

– Evaluation 3 months post-treatment

Pre-treatment Swallowing Exercises

• Carroll et al, 2008– Significant benefit for pre-treatment group in:

• Epiglottic inversion (p= .05)

• Tongue base proximity to posterior pharyngeal wall (p= .025)

Follow up Plan

• Ongoing monitoring

• Encourage oral intake as tolerated

• Encourage daily exercise

• Re-evaluate at the conclusion of tx

Multidisciplinary assessmentPre-treatment SLP consultationVoiceSwallowingClinical controversies

Common Voice Complaints

• Reduced pitch variability

• Reduced ability to sing

• Reduced loudness

• Reduced phrase length

• Hoarse or breathy vocal quality

• Vocal strain

• Vocal fatigue

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, 2001Meleca et al, Laryngoscope, 2003

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

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, 2001Meleca et al, Laryngoscope, 2003

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)

Voice Therapy

• Improve vocal hygiene

• Improve glottic valving

• Balance respiratory, phonatory, and resonant systems

• Improve pliability and pitch variability

• Reduce supraglottic constriction

• Compensate

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

Hydration and Voice

• Improving hydration may:– Reduce phonation threshold pressure– Reduce patient perceived vocal effort– Improve vocal quality

Solomon & DiMattia, Journal of Voice, 2000Verdolini et al, JSHR, 1994Yiu and Chan, Journal of Voice, 2003

Multidisciplinary assessmentPre-treatment SLP consultationVoiceSwallowingClinical controversies

• Food gets stuck in the throat

• Pills don’t go down well

• Coughing or choking

• Foods get stuck in the mouth

• Mouth too dry for many foods

Common Swallowing Complaints

Characteristics of Dysphagia

• Goguen et al, Otolaryngol Head Neck Surg, 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

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

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

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

Recovery

• Goguen et al, 2006

Months % Soft or Regular Diet

% GT Removed

3 17 27

6 53 63

9 70 80

12 80 81

24 97 90

Recovery

• Dworkin et al, Dysphagia, 2006– N = 14 with Stage III/IV laryngeal SCCA– <12 months: 43% regular/near normal diet– >12 months: 86% regular/near normal diet

Regular diet 3

Near normal diet 6

Puree 3

Gastrostomy tube

2

Recovery

• Pauloski et al, 2006

% with <50% oral intake

% with non-normal diet

Pre-tx 5.1 37.8

1 mos post 39.5 74.4

3 mos post 25.9 63.6

6 mos post 19.1 56.0

12 mos post 12.5 40.3

Exercise Principles

• Goal selection• Specificity of training• Overload/progression

Clark, AJSLP, 2003

Exercise Principles

• Goal selection

• Specificity of training

• Overload/progression

Clark, AJSLP , 2003

Exercise Principles

• Goal selection

• Specificity of training

• Overload/progression

• Clark, AJSLP , 2003

Therapy Targets

• BOT retraction

• Tongue strength

• Laryngeal elevation

Goguen et al, 2006

Logemann et al, 2006

Pauloski et al, 2006

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, 2002Yoneyama et al, J Am Geriatr Soc, 2002

Medical/Surgical Tx for Dysphagia/Dysphonia

• Dilatation– Surgical– Chemical

• Cricopharyngeal myotomy/Botox• Vocal fold medialization by injection• Medialization thyroplasty

Factors Affecting Recovery

• Tumor site– Larynx, hypopharynx, BOT pharyngeal wall

have more difficulty than tonsil, soft palate, oral cavity, nasal cavity, nasopharynx, UNK primary

– Age– Baseline dysphagia

Caudell et al, Int J Rad Onc Biol Phys, 2008

Factors Affecting Recovery

• Mucositis (Jones et al, 2006)

• Early treatment (Lazarus et al, 1996; Pauloski et al, 2000; Rosenthal et al, 2006)

• NPO intervals (Gillespie et al, 2004)

Xerostomia Visual Inspection of the Mouth

Photo courtesy of James Sciubba, DMD, PhD

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

When saliva productioncannot be stimulated, 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

• Changes in diet to avoid damage to fragile mucosa– Avoid dry, spicy foods – Avoid temperature

extremes– Avoid alcohol, tobacco,

caffeine, sugar containing products

• Routine and professional dental care

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

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)

Criteria for Trismus

• Normal MIO 46+7mm

Steelman et al, Mo Dent J, 1986

• MIO < 30 – 35mm

Buchbinder et al, J Oral Maxillofac Surg, 1993; Dijkstra et al, J Oral Maxillofac Surg, 2006

Treatment for Trismus

• Buchbinder et al, J Oral Maxillofac Surg, 1993– N = 21 s/p resection of oral SCCA and

radiation tx <5 years

Group Net increase at 6 wks

Exercises 6.0mm (+/-1.8mm)

Tongue blades 4.4mm (+/- 2.1mm)

Therabite 13.6mm (+/- 1.6mm)

Treatment for Trismus

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

MIO mm12 - 48 wks post op

Initial 30 (24 – 38)

Final 40 (30 – 57)

p < .01

Treatment for Trismus

• Dijkstra et al, Oral Oncology, 2007

Trismus related to head/neck SCCA

Trismus not related to SCCA

Mouth opening

mean (SD)

19.3mm (7.4) 17.6mm (6.8)

Increase in mouth opening

mean (SD)

5.5mm (6.0) 17.1mm (9.0)

p < .05

Jaw ROM

• Mandibular opening/lateralization

• Pretend chewing

• Three finger check

Multidisciplinary assessmentPre-treatment SLP consultationVoiceSwallowingClinical controversies

To tube or not to tube…

• Body Mass Index (BMI) effects– Low BMI associated with:

• Higher probability of recurrence• Lower overall survival

McRackan et al, 2008

To tube or not to tube…

• Patients at greatest risk for weight loss during treatment– Nasopharynx or tongue base primary– Addition of chemotherapy to radiation– Hyperfractionated radiotherapy– Significant pre-treatment weight loss (>10% of weight 6

months prior to treatment)– Eating difficulties prior to treatment– Unpartnered male patients

Beaver et al, 2001; Larsson et al, 2005; Konski et al, 2006; Piquet et al, 2002

To tube or not to tube…

• Positive effects of prophylactic tube feeding– Reduction in weight loss for elective,

prophylactic tube feeds in contrast to therapeutic tube feeds or no tube (Chen et al, 2008)

– Reduction in admissions for dehydration during treatment (Scolapio et al, 2001, Beaver et al, 2001)

– Avoidance of treatment interruptions

To tube or not to tube…

• Mekhail et al, Cancer, 2001– Those with NGFT

• Less long term dysphagia• Shorter FT duration• Less need for dilatation

– Stenting function– Motivate patients to swallow sooner

To tube or not to tube…

• Negative side effects of tube– Increased discomfort at tube site– Tube blockage– Tube migration or dislodgement– Peritonitis, perforation, tumor seeding

(Rosenthal et al, 2006)

– May lead to patient over-reliance• Scar and stricture formation (Caudell et al, 2008)

How We Address It

• Patient education

• Patient encouragement

• Regular follow up in high risk patients

• Suggest prophylactic tube for patients in high risk groups

To stim or not to stim…

• Pro– Combine with other tx techniques

• Effortful swallow

– Use as a resistance exercise• Mendelsohn

– May decrease fibrosis

To stim or not to stim…

• Con– Cannot stimulate deep muscles– Contraindicated in SCCA

• Increasing metabolic activity