Transcript Approaches to Assessment and Treatment of Patients

Approaches to Assessment and
Treatment of Patients with Head
and Neck Cancer for the SpeechLanguage Pathologist
Megan Hyers, MS, CCC-SLP
Rebecca Schob, MsED, CCC-SLP
Providence Portland Cancer Center Amphitheater
March 29, 2014
Outline
• Overview of anatomy, staging, tumor size,
and multidisciplinary team. Treatment
approaches of Head and Neck Cancer, and
how they impact speech, swallowing, and
voice
• Evaluation and Treatment approaches status
post surgery. Surgical reconstruction
approaches, and impact on communication
and swallowing.
Outline continue
• Evaluation and Treatment approaches during
chemo-radiation, and impact on
communication and swallowing
• Post treatment outpatient role
• Evaluation and Treatment for patients with a
laryngectomy. Focus on pre-operative, postoperative, and long-term
treatment. Discussion of communication
options.
• Case studies and questions
Incidence
• Head and neck cancer accounts for 3-5%
of all cancers in the United States
• 35,000 new oral and oralpharyngeal
cancers
• About 6,800 deaths
• 12,360 new laryngeal cancers
• About 3,650 deaths
• More men than women will be affected
• More common over the age of 50
Incidence (cont)
• Rate of new cases dropping past few
decades
• Recent rise in cases of oral pharyngeal
cancer related to Human Papilloma
Virus (HPV)
– Especially in white men under 50
• Rates vary among countries with much
higher rates in Hungary and France
Cancer Staging
• Describes the extent or severity
• TNM system (tumor, nodes, metastasis)
– For example T3N2M0
– T=extent of tumor (0-4)
– N=spread to nearby lymph nodes
– M=whether any distant body parts are involved
• TNM corresponds to one of five stages (Stage 0Stage IV)
Nasopharyngeal Cancer
• Nose and paranasal
cavities including sinuses
• Different types of
cancers can develop
depending on the type of
tissue
• Impacts smell, breathing,
and resonance
Nasopharyngeal (cont)
• Rare, more common in other parts of the
world (Asia)
– Males from Kwangtung Province (Cantonese)
40 times that of US Caucasian males
• Twice as high in men than in women
• Tends to occur in people between the
ages of 45-85
• 54% of patients survive 5 years after
diagnosis
Oral Cancer
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Lips
Cheeks
Gums
Floor of mouth
Hard palate
Oral Cancer (cont.)
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Soft palate
Tongue
Tonsils
Mandible
Salivary glands
Oral Cancer (cont.)
• More than 90% are squamous cell carcinoma
• Rates are more than twice as high in men
than women
– Except women have a higher incidence of salivary
gland cancer
• 84% of patients survive at least 1 year after
diagnosis
– 59% survive 5 years
– 48% survive 10 years
Laryngeal Cancers
• Larynx-including the
vocal cords
• Epiglottis
• Base of tongue
• Pharyngeal walls
Laryngeal Cancers (cont.)
• Hypopharynx/Supraglottis-from the epiglottis
to the arytenoids
• Subglottic-below the vocal cords
• 95% are squamous cell carcinomas
• One of the most common types of head and
neck cancer
• 64% survive 5 years
Causes of Head and Neck
Cancer
• Overwhelming majority of head and
neck cancers are related to prolonged
exposure to environmental factors
Causes (cont.)
• Tobacco: Tobacco contains many
carcinogens
- Pipe smoking associated with lip cancer
- Cigarette smoking plays a causative role in
tongue, pharyngeal, laryngeal, esophageal, and
lung cancer
- Reverse smoking (where the burning end of the
cigarette is kept in the mouth), which is popular in
parts of India, Sardinia, Venezuela, and Panama
is associated with hard palate cancer
Causes (cont.)
• Sunlight-Lip cancer, skin cancer
• Frequent and heavy alcohol consumption
– Synergistic with tobacco
– Ethanol per se, not a carcinogen, other factors
implicated
• Occupational Factors-nickel workers, wood
workers implicated in paranasal sinus
cancer
Causes (cont.)
• Epstein-Barr Virus-possible etiological role in
nasopharyngeal carcinoma
• Poor oral hygiene-oral cavity, especially floor
of mouth, tongue, and alveolar ridge
• Nutritional deficiencies-specific role not
established, but an area of research
• Reflux
• Exposure to second hand smoke
Causes (cont.)
• Genetic factors
– genetic link is not completely understood
– some neoplasms have had recent chromosomal
identification
• Radiation
- Ionizing radiation, which was used in the past to
treat acne, tonsillar hypertrophy, and enlarged
thymus in newborns has led to increased risk of
some cancers
• Weakened immune system
• Human papillomavirus (HPV)
Human Papiloma Virus
• In 1970’s, HNSCC has decreased along similar trend
to reduced cigarette smoking
• Large increase in HPV positive tumors since 1970s
– HPV oralpharyngeal SCCC increased 225% between 19882004
• 70% of new cases of oral cancers linked to HPV
– Surpassed tobacco use as leading cause
• Usually diagnosed at higher stage
HPV continued
• Population is different
– Younger
• Oral HPV infections peaked in 30-34 year olds and 60-64
year olds
– Healthier
– Mostly male
• 6-7 times more common in men as opposed to general
oral cancers are 2 times more likely in men
• HPV tumors respond better to treatment and higher
survival rates
– 2-3 year survival is 80-95% (HPV negative is 57-62%)
Prevention of H + N Cancer
• According to WHO: “While tobacco use is the single
largest causative factor -accounting for about 30% of all
cancer deaths in developed countries and an increasing
number in the developing world – dietary modification and
regular physical activity are significant elements in cancer
prevention and control. Overweight and obesity are both
serious risk factors for cancer. Diets high in fruit and
vegetables may reduce the risk for various types of
cancer, while high levels of preserved and/or red meat
consumption are associated with increased cancer risk.”
Multidisciplinary Team
• Surgeon
• Radiation
Oncologist
• Medical Oncologist
• Speech Pathologist
• Physical Therapist
• Occupational
Therapist
• Dentist
• Dietician
• Social Worker
• Respiratory
Therapist
• Nursing
Treatment Options
• Surgery
• Radiation
• Chemotherapy
Surgery
Surgery types
• Most common types
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Glossectomy/partial glossectomy
Tonsilar
Base of tongue
Floor of mouth
Mandible
Maxilla
Buccal
Laryngectomy
More surgery
• Radial forearm free flap (RFFF)
• Fibular free flap (FFF)
• Transoral Robotic Surgery (TORS)
– Minimally invasive
– Reduce need to split the jaw
– Reduce infection risk
– Shorted hospital stay, faster recovery
TORS
Protocols for Surgeries
• Unofficial
• MD’s will clarify for specific patients
• Surgeons: Drs Bell, Dierks, Bui,
Petrisor, Ueeck
Neck Dissection Only
Neck Dissection Care
• Eating: ASAP
– Start with clear liquids, advance as tolerated to
regular
• Shower: ASAP
– Back to the shower head
– Do not submerge wound for 2 weeks.
– Light antibiotic ointment layer allows small amount
of water to trickle over wounds without problems
Neck Dissection Movement
• Ambulate: ASAP, when awake and alert
• Avoid exertion, heavy lifting/straining, bending for 2
weeks
• Dictated by patient comfort, self-limiting for 2 weeks
• Neck turning: initially guarded enough to make
driving and rapid reactions difficult
• Spinal Accessory Nerve almost always spared
• If injury to Spinal Accessory Nerve:
• Symptoms may not appear for 1 week post
surgery
• Can take 6 months to reconnect
Spinal Accessory Nerve
Spinal Accessory Nerve and
Neck Dissection
• Goal of Radical Neck Dissection is to remove lymph
node metastasis in one or both sides of the neck, and
removes the Spinal Accessory Nerve
• Modified Neck Dissection will spare the Spinal
Accessory nerve
• Even when the SAN is spared, problems can arise
with the shoulder
• SAN innervates the sternocleidomastoid muscle (tilts
and rotates the head) and the trapezius muscle
(several actions on the scapula, including shoulder
elevation and adduction of the scapula)
Spinal Accessory Nerve
• PT or OT help the patient to maintain or regain
passive ROM of the shoulder.
– This can limit or prevent stiffness of the shoulder
capsule and ligaments that can arise with
malalignment of the shoulder and adhesive
capsulitis.
• Significant improvement in mobility, pain, quality of
life, and return to previous occupation seen with
patients receiving therapy.
– Early and prolonged therapy, beginning within 1
month of surgery and lasting, on average, 3
months.
Glossectomy,
Hemiglossectomy
Glossectomy,
Hemiglossectomy
• Eating:
– Free Flap: 1-2 weeks before eating (tube feeding)
– No Free Flap: eating ASAP
• Shower: same as Neck Dissection
• Movement: same as Neck Dissection
Base of Tongue
• Deficits depend on how much tissue is
removed
• Can affect swallowing and speech
• Pain can limit intake
Radiation Therapy
Radiation Therapy
• Intensity-modulated radiation therapy
(IMRT)
– precise radiation doses to a malignant tumor
or specific areas within the tumor.
– allows for the radiation dose to conform more
precisely to the three-dimensional (3-D) shape
of the tumor
– allows higher radiation doses to be focused to
regions within the tumor while minimizing the
dose to surrounding normal critical structures.
• Spares healthy tissue and organs
IMRT
Chemotherapy
Chemotherapy
• Cisplatin
– Cross links DNA, which ultimately triggers
apoptosis (programmed cell death)
– Traditionally 100 mg/m² every 3 weeks
– To attempt to reduce side effects, some
doctors using 33 mg/m² every week
• The research has mostly been done on the
traditional method
Cisplatin Side Effects
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Kidney damage
Nerve damage
Nausea and vomiting
Ototoxicity
Electrolyte disturbances
Decreased sense of taste
Fatigue
Exercise in Dysphagia Rehabilitation
How common is dysphagia in
H and N cancer?
Prevalence of Dysphagia in
H + N Cancer
• Patients with oral-pharyngeal dysphagia: 50.6%
• Mostly to solid foods: 72.4%
• Patients with total glossectomy and
chemoradiotherapy had the highest rate of
dysphagia.
• Nutritional support: 57.1%
• Malnutrition: 20.3%
• Patients reported a decrease in their quality of life
due to dysphagia: 51%
Long-term prevalence of oropharyngeal dysphagia in head and neck cancer patients:
Impact on quality of life, Garcia-Peris, P; Clinical Nutrition, Dec 2007
Swallowing disorders in head and neck cancer
patients treated with radiotherapy and adjuvant
chemotherapy
Lazarus, CL, et al, Laryngoscope; 1996, Sept, 106
• Study of 9 patients undergoing external
beam radiation and chemo for H + N
Cancer
• 7 of the 9 experienced reduced posterior
tongue base movement toward the
posterior pharyngeal wall and reduced
laryngeal elevation during the swallow
• All 9 patients experienced reduced
efficiency of their swallowing compared to
normals
Do exercises help with
swallowing?
Strength-Training Exercise in Dysphagia
Rehabilitation: Principles, Procedures, and
Direction for Future Research
Burkhead, L, et al; Dysphagia 2007 (22)
• Muscles involved in mastication and swallowing
exhibit unique fiber types, architecture, and
composition, unlike any other human skeletal
muscle.
• They undertake a wide spectrum of actions
– respiration, speech, mastication, and swallowing
• Demand may shift rapidly from tonic contractions
for maintaining airway patency during inhalation to
rapid low-force movements during speech to
forceful bursts during chewing.
• Contain Type I, IIa, and IIb fibers, with a
predominance of Type II fibers.
Continue of Strength Training
• Simply swallowing food or liquid does not
provide the degree of load needed to force
adaptations in the neuromuscular system
to increase strength
• Exercise programs usually involve nonswallowing strengthening with good
results, but will have even greater effect
when in conjunction with task-specific
swallowing practice
Dysphagia treatment after
surgery
Post-op Swallowing Exercises
• ALWAYS check MD’s restrictions prior to starting PO
• Gentle in beginning secondary to tenderness and
pain
• Related to location of surgery
– Jaw=opening/closing jaw
– FOM=tongue, jaw
– Tongue=see glossectomy exercises
• Stress good oral care
• As surgery heals, exercises can be progressed
Glossectomy
• Must address tongue movement for mastication,
swallow and articulation
• Total glossectomy will have difficulty with articulation,
and manipulation of all boluses.
– Compensatory strategies such as positioning, use
of buccal muscles
Glossectomy Continued
• More common for a partial glossectomy, leaving a
remainder of the tongue.
– Radial Forearm Free Flap including skin and blood
supply
– Flaps have no motor function, so they are unable to
propel the bolus
– Sensation can vary, which will impact the ability to
sense the bolus in the mouth
• The patient should also be taught self examination to
insure that he/she is not damaging the remainder of the
tongue while chewing
Partial glossectomy exercises
Adapted from Dennis Fuller, Ph. D
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Mandible opening; open mouth as far as possible. This is good
exercise for stimulation of tongue base.
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With a tongue blade; push non-affected side of tongue against blade for
count of three and relax.
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Attempt to lick alveolar ridge, left to right, then right to left.
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Attempt to lick lip, left to right , then right to left.
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Attempt to push non-affected cheek out and hold for count of three.
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With teeth together and lips closed, attempt to push tongue forward and
hold for count of three.
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Repeat #6 but push tongue to roof of mouth for count of three.
Continue Glossectomy exercises
• For prevention of saliva pooling, pucker lips and do a
strong suck-back and swallow.
• Any attempted articulation is good stimulation for
tongue movement
– Start with non-glossal sentences and then move into some
that have glossal movement.
– i.e, "Why buy ham mom", "May I have more" and move to,
"Head light" "small hotdog"
• If the patient is not a risk for aspiration, any swallowing
activity is good stimulation for tongue movement. Start
with a consistency that is easy to manage such as
pudding or honey and move to a thinner consistency.
What does chemoradiation do
to swallowing?
Effects of Chemoradiotherapy on Tongue
Function in Patients With Head and Neck Cancer
Lazarus, CL, Perspectives on Swallowing and Swallowing Disorders, 18 55-60, June 2009
• Radiation can cause neuropathies, specifically,
within the hypoglossal nerve
• Tongue strength has been found to be impaired
following radiation to the head and neck.
– Decrease in lingual strength can occur long after
completion of radiation and can have a negative
effect on swallowing
• Exercise programs that target pharyngeal
structures as well as the tongue may play a
critical role in maintaining and improving
swallow functioning
Do exercises help with
swallowing for individuals with H
and N cancer?
Pretreatment, Preoperative Swallowing
Exercises May Improve Dysphagia Quality of
Life
Kulbersh, BD MD, et al, Laryngoscope, 116, 6. June 2006
• 25/37 patients were started on swallowing
exercises 2 weeks prior to beginning radiation
• The M.D. Anderson Dysphagia Inventory
(MDADI) was administered 14 months after
treatment
• Those patients who completed the swallowing
exercises, showed improved scores on the
MDADI as compared the the control group
• Separate analysis demonstrated improved
quality of life for those that did the exercises
Dysphagia treatment during
Chemo-Radiation Treatment
Pretreatment Dysphagia Protocol for the Patient With
Head and Neck Cancer Undergoing Chemoradiation
McColloch, NL, et al, Dysphagia, 19, June 2010
• Initial meeting:
– Swallow evaluation
– may include diet modifications, postural changes, and oral
motor exercises.
• Ongoing contact with the patient during treatment is a
priority
– reinforce the exercise protocol,
– assess the risk of aspiration,
– continually evaluate the patient’s hydration and mucous
status
• Oral-motor exercises focus on maintaining tongue range
of motion and strength, hyolaryngeal elevation, vocal fold
mobility, and rotary jaw motion.
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.
• Mendelhsohn Maneuver and Shaker Exercises
• Jaw range of motion exercises: maintain rotary
movements of mastication and decrease the
chance of trismus
Swallowing Treatment During Radiation
• Begin treatment at start of radiation, however patients
will usually be tolerating PO
• Start oral-motor and swallowing exercises
– Tongue press, Masako, Super Supraglottic have
been proven
– Reinforce importance of continuing through
treatment and after
• Educate on keeping moisture in mouth
• Continue to treat through Radiation to assess diet
tolerance, continuing exercises, comfort measures
– Swallowing will change as treatment progresses
Impact of disabilities on
patients
Disability in Patients With Head and Neck
Cancer
Taylor, J. C, MD, et al, Arch Otolaryngology Head Neck Surg. 2004;130:764-769
• More than half of the patients were disabled by their
H + N cancer or treatment.
– About half of those who underwent a neck
dissection, were unable to work afterward
• Those undergoing chemotherapy or neck dissection
or have high pain scores are at increased risk
• While undergoing chemo, they often develop
profound deconditioning or fatigue. They also often
have mild to moderate neuropathies, dysphagia, loss
of taste, and potentially other adverse effects
Physical Activity Correlates and Barriers
in Head and Neck Cancer Patients
Rogers, LQ, et al, Support Care Cancer, 2008, 16
• Physical activity improves cardio-respiratory fitness
during and after cancer treatment, symptoms and
physiologic effects during treatment, and vigor posttreatment
• Most prevalent barriers to physical activity include
enjoyment, and treatment related difficulties
– dry mouth or throat, fatigue, drainage in mouth or
throat, difficulty eating, shortness of breath, and
muscle weakness.
• Efforts to enhance exercise adherence should focus
on enjoyment and managing treatment barriers
Physical activity and quality of life in head
and neck cancer survivors
Rogers, LQ, et al; Support Care Cancer; 2006, Oct; 14
• 59 H + N survivors were given survey of physical,
emotional, social and functional well being
• Few H + N Cancer survivors are participating in
moderate or vigorous exercise. Over half are
sedentary
• Meaningful associations between total exercise
minutes, QoL, and fatigue were noted.
• Appears that an exercise program may benefit
this survivor group.
Laryngectomy
Laryngectomy continue
• Eating: NPO 2 weeks
– NG tube feedings
– Cleared with a modified barium swallow study first
• Shower: Unique issues
– Back to the shower head
– Open hand, press anteriorly to protect the stoma
• No soaking in hot tub or bathtub
• No Chiropractor or cervical manipulations
Laryngectomy Communication
Options
• Electrolarynx
• TEP (tracheo-esophageal prosthesis)
• Esophageal speech
Electrolarynx
• Usually taught to every patient post-laryngectomy.
– Even if it is not their permanent communication
choice, it is a backup for emergencies
• Ordered prior to leaving the hospital
• Start with an oral adaptor because of swelling
Electrolarynx continue
• Oregon Telecommunication Devices
Access Program
• Attached to the phone
• Must have a land line
• If patient lives alone, good option for
emergencies
IPALPAT
Adapted from “Total Laryngectomy: SLP Survival Guide,” Benjamin, Meaghan Kane, Bunting,
Glenn, and DeLassus Gress, Carla, ASHA Convention 2011
• I=Information
– The patient is informed about the benefits of
artificial larynges and selection of the proper
device
– Influential factors:
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Purchase price
Upkeep
Availability
Possible modifications
Expediency
Post-operative complications
Patient preferences
IPALPAT continue
• P=Placement
– Optimal placement of device to achieve the best
clarity of sound and resonance
– With intra-oral devices appropriate placement of
the intra-oral tubing to achieve the best clarity of
sound and resonance
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Bend it about 45 degree angle
Lay upon tongue or up against roof of mouth
Usually lateral region along one side of tongue
May consider cheek placement if adequate resonance and
tolerated by patient
• Insert only 1-2 inches of tubing with upward or downward
orientation
• Practice speaking around the tube, don’t hold it with lips,
tongue or teeth
IPALPAT continue
• A=Articulation
– Shaping sound into speech using the
tongue, teeth, lips, and palate for precise
sound production
– Over articulation is recommended to
improve overall intelligibility
– Placement of the artificial larynx should not
result in obstruction of the mouth as some
lip reading may be used by the listener
IPALPAT continue
• A=Articulation continue
– Plosive and fricative voiceless features (p,
t, k, s. sh, ch, f, th) must be produced with
effort over the sound of the electrolarynx
– Keep it practical, avoid working on single
words unless necessary for specific
articulatory drills
– Voiced sounds are better perceived than
voiceless
IPALPAT continue
• T=Timing
– Effective use of on/off button to coincide
with appropriate phrasing
– Biggest challenge is the learning curve to
activate device as speech is initiated and
turn off device at the end of the final word
in a phrase
– Using 7-10 syllable phrases and training
the patient to learn to phrase as they turn
sound on and off is effective way of
teaching this portion
IPALPAT continue
• PAL=Pitch and Loudness
– The pitch of the electrolarynx is set by the SLP during
the initial artificial larynx treatment session
• Adjusted to a level appropriate to the patient’s age
and gender
– Loudness/Volume adjusted so that the patient can hear
himself clearly
– Individuals can be taught to modulate pitch for more
natural intonation patterns by manipulating the buttons
on the external device
IPALPAT continue
• PAL=Pitch and Loudness continue
– Instruction in basic volume adjustments
specific to individual’s device should be
offered within the first few treatment
sessions
– Keep volume as low as possible
– Keep pitch as low as acceptable
IPALPAT continue
• Distracting behaviors
– Refer to any behavior that draws attention
to the patient in a negative way
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Stoma blasting
Head tilted back
Grimaces
Atypical arm postures
– These behaviors should be addressed
during each session
Other Communication Strategies
• When talking on the phone, hold
receiver between mouth and nose
• Face communication partners
• Exaggerate facial expression to
emphasize verbal expression
TEP (tracheo-esophageal
prosthesis)
• Most common communication choice
• Sounds more “normal”
• Not perfect choice for every one
Esophageal Speech
• Much less common
• Difficult to learn
• “Burp speech”
Post-laryngectomy stoma care
• Clean around the stoma multiple times per day
– May require some cleaning with hemostats,
gauze, and saline spray to clear dried secretions
• Saline boluses
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Use saline “bullets”
Start with small amount (3-5 ml)
Squirt directly into the stoma
Cough if able, or suction after
Do 2-3 times per day
Lary tubes and HMEs
• Lary tubes
– Cleaned throughout the day
– Rinsed under running water
– Replaced using water based lubricant
• HME (Heat Moisture Exchange)
– Do not use with trach mist
– Worn as long as tolerated (trach mist if not on)
– Change if coated or at least every 24 hours
Adhesive base plates
• Can be worn if lary tube is not tolerated,
but always check with surgeon first
• Immediate post-op, only the optiderm
• Housing unit for HME
• Can stay on without HME in and trach
mist on
Post-surgical issues
• Trach
– Unable to have Valsalva-Open system
• Can impact ability to bear down for bowel
movement (often issues with pain medications)
• Teach them to cover trach, if able, when having
bm
• NG tube
– Can be irritating when rubbing on post-surgical
tissue
Support Groups
• Head & Neck Cancer Support Group:
Education and support for individuals and
families coping with the
– Impact of a head, neck or oral cancer
diagnosis.
– Legacy Good Samaritan Medical Center: 1st
Thursday, 4-5:30 pm
• Conference Room 219, Good Samaritan Building 3,
2nd floor
• Contact Julia Robinson, MS CCC-SLP at
[email protected] or 503-413-2841
Support Groups continue
• Nu Voice Club
– Meet at American Cancer Society
• 0330 SW Cury St, Portland, OR
– 1:00 3rd Saturday of each month
– Call Blayne Graves 503-795-3918
– Or Email [email protected]
Thank you for coming!