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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
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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 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) • DynasplintTrismus 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
Mucositishttp://www.caphosol.ca/health-care-professionals Stage 1 (above) Stage 3 (below) Stage 2 (above) Stage 4 (below)
Px & Tx of Oral Mucositishttp://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 (percutaneousflurosopicgastostomy) 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!!
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/DysarthriaTx • 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: lymphedemavs other edema • fluctuations in edema • onset of edema vsTx/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)