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Management of Complicated Dysphagic Head and Neck Cancer Patients Session Number: 2418 Saturday, November 22, 2008 -- 1:00 pm - 3:00 pm Room: W183B McCormick Place West Angela Campanelli, MS, CCC-SLP, BRS-S Kettering Medical Center, Kettering, Ohio The Entertainer 70 years old; non-smoker, non drinker Husband Avid Runner Entertainer playing the accordion and singing Action and results oriented Medical History 2000 October Chemo Radiotherapy for T4N02cM0 squamous cell carcinoma of right retromolar trigone CT showed no response after 4500cGy…Total 7000Gy – PEG – trismus 2005 March Completed voice therapy 2006 July Recurrence/Surgery The Surgery Pectoralis mucocutaneous flap repair Partial pharyngectomy Partial palatal resection Partial glossectomy Hemi-mandibulectomy with Titanium Preservation of CNXII. PEG/NPO Figure 1. Pectoralis Major Flap in Composite Lateral Skull Base Defect Reconstruction, Vicente A. Resto; Michael J. McKenna; Daniel G. Deschler, Arch Otolaryngol Head Neck Surg. 2007;133:490-494. 1420_2418Logemann_Jerilyn_A._106563_Nov18_2008_Time_125055PM.doc 2 Comprehensive Therapy 2006 December – 2007 February Tongue range of motion Lip strength and closure Suck swallow Swallowing trials with water syringe compliance was another matter… Therabite 7x7 Vertical mandibular excursion increased from 11 to 22 mm VFSS April 2007 Impaired oral transit, improved lip closure Delay of swallow reflex with silent aspiration of nectar thick Absent pharyngeal stripping, Tongue could not meet posterior pharyngeal wall due to debulking Apparent high grade stricture of UES He has not done his home program since February Referrals Gastroenterologist for dilatation Primary Care Physician for Prevacid solutab (to reduce risk of edema and stricture of UES due to GER) Physical Therapy for Neck Mobility Esophageal Stricture Clinical Observations Neck immobility and rigidity Velo-pharyngeal insufficiency (VPI) with hypernasal speech Left side of tongue barely touches teeth and right is mostly pectoralis flap with accompanying dysarthria Sensory impairment tongue and lips Therapy 2007 April Laryngeal Valving – Effortful breath hold (improved from 2/5-5/5) 1420_2418Logemann_Jerilyn_A._106563_Nov18_2008_Time_125055PM.doc 3 Tongue/Lip Strengthening and Range of Motion – lingual “tip” to roof of mouth and teeth; protrude, curl around teeth; back of tongue “k”(best if supine), labial resistance, suck-swallow, Mendelsohn maneuver, mid-tongue elevation (could not do), Shaker maneuver (had to discontinue) – Sensory Stimulation to facilitate motor (brushing, quick strokes, gentle touch to soften tissue) – Velo-pharyngeal Valving improved awareness and artic contact with nasal occlusion Progress and Problem Solving Good progress from April-June – Range of motion of the tongue increased (1to 3cm past midline to the right) – UES dilated from12 to 15 mm diameter (45 French is circumferential dimension) – Increased neck range of motion “I feel safer now when I ride my bike.” – 0% to 50% produce t,d with nares occluded Referral to Prosthodontist for Maxillary Tx …July “I haven’t done much.” Palatal Prosthesis with Obdurator Obtained early October 2007 Changes and with Wearing the Prosthesis A-P transit and timing of swallow reflex improved 3 cc size bolus of nectar with Super-Supraglottic Swallow; 4/5 times effective Sustain “e” improved from 26-35 sec. Head turn left improved resonance balance and decreased nasal air emission Improved tongue to alveolar ridge contact Challenges Required about 30sec of Therabite to allow prosthesis to fit in mouth Pain on right side where metal attached Had to use a tool to loosen from teeth to remove “My mouth is already sore and then when I put this in it’s worse.” By November 13 use was discontinued as swallow was worse with increased choking, and stasis at obdurator. 1420_2418Logemann_Jerilyn_A._106563_Nov18_2008_Time_125055PM.doc 4 VFSS 2007 November 21 Therapy break from July until prosthesis obtained in October Home feeding with syringe, poor oral-motor integration with worsened A-P transit Usually absent swallow reflex Problems Pain and muscle spasm on right from base of neck up to top of head with increased muscle effort (stopped Shaker) Therapy break December due to insurance limitations Next At wife’s insistence they tried Vital Stim – ? Vagal reaction Still NPO “I made an attempt.” at oral trials. “I feel like it doesn’t go down.” Epilogue The Entertainer became an Advocate Active in Support for Person’s with Oral Head and Neck Cancer SPOHNC Found a new normal “I wished I would have been given an honest answer regarding my swallowing. I was surprised that it never came back.” 1420_2418Logemann_Jerilyn_A._106563_Nov18_2008_Time_125055PM.doc 5 Donna Lundy, Ph.D. CCC-SLP, BRS-S University of Miami Miller School of Medicine, Florida Organ Preservation: Larynx Chemo-xrt protocols Partial Laryngectomy options: – Supraglottic – Hemi-vertical – Supra-cricoid – Near-total – Other modifications Case Presentation: JG 61 YOM with prior h/o T1 bil. VF treated with Radiation (2004); now w/increased hoarseness and bx from ant. commissure c/w spindle cell cancer staged as T4No recurrence (6/07) Medical hx: – HTN Social Habits: – Non-smoker – Social alcohol usage Works as “tool man”; runs own business and needs voice Recommendation: Total Laryngectomy – Pt refused – Agreed to supra-cricoid if possible Supracricoid Laryngectomy Bilateral glottic lesion Possible as surgical salvage May resect one arytenoid Supracricoid Laryngectomy vs. TL & Dysphagia Retrospective study of 10 pts. s/p supracricoid vs. 10 s/p TL + TEP FEES in 7 & MBS in 3 (refusal of FEES) Results: – Significant premature spillage into valleculae – Chronic pooling of food residuals & secretions in hypopharynx w/intermittent aspiration during respiration – Excessive throat clearing & coughing 1420_2418Logemann_Jerilyn_A._106563_Nov18_2008_Time_125055PM.doc 6 – Sensate aspiration w/adequate clearage – Prolonged use of feeding tube & need for swallowing therapy • Dworkin et al., 2003 JG continued 7/2/07: pt. underwent Supracricoid Laryngectomy, left neck dissection, & trach 7/25/07: 1st MBS: insert video 7/25 – 9/5/07: Intensive swallowing therapy – Masako Maneuver – Mendelsohn Maneuver – Super-supraglottic swallow – Resistance exercises 9/5/07: Repeat MBS & Endoscopic view 10/9/07: Stridor noted during Rx; ENT contacted; emergency trach – Recurrence found during procedure 10/29/07: Total Laryngectomy, right neck dissection, TEP Story is not over… INDICATIONS FOR TL After failure of organ preservation therapy For pt.’s with host or tumor characteristics that prevent non-surgical treatment or conservation resection For pt.’s that desire surgical vs. non-surgical approach All TLs are not created equal TL after radiation therapy TL after radiation therapy and prior surgery TL with BOT extension TL with partial pharyngectomy Laryngopharyngectomy with myocutaneous flap Laryngopharyngectomy with jejunal free flap Laryngopharyngectomy with radial forearm free flap Laryngopharyngectomy with esophagectomy (gastric pull-up) Removal of Larynx Results in: Increased resistance to flow from loss of sup & ant laryngeal movement Reduced opening of the UES Loss of sub-atmospheric pressure needed to move bolus through collapsed pharynx PTTs double (McConnel et al., 1986) Tracheostoma results in increased tortuosity of pharynx 1420_2418Logemann_Jerilyn_A._106563_Nov18_2008_Time_125055PM.doc 7 JG continued 11/12/07: T-E prosthesis placed and therapy begun; soft diet 11/21/07: stomal breakdown w/stenosis 12/28/07: recurrence found at esophageal juncture; T-E prosthesis removed; swallowing reduced to liquids only 1 – 4/08: Chemo and repeat XRT 6/6/08: stomal recurrence 6/08: outside consultation & more chemo 7/08: pt. expired Summary H&N pts. are becoming more complicated Status may continue to change Goals and outcomes need to be continually modified to reflect pt’s changing status Quality of Life is everything! 1420_2418Logemann_Jerilyn_A._106563_Nov18_2008_Time_125055PM.doc 8 Mario Landera, M.A., CCC-SLP University of Miami Miller School of Medicine, Florida Case Presentation: LA 62 yo male diagnosed with a T1N2a SCC of the right base of tongue Medical hx: bilateral herniorraphies, rhinoplasty, laminectomy Social hx: h/o smoking 1/2 ppd x 30+ years (quit 1994); social drinker Retired businessman, very active runner Medical Treatment March 2003: – Transhyoid base of tongue resection with bilateral neck dissection and pharyngeal reconstruction April 2003: – First MBS performed MBS Results April 2003 Oral prep: – Unremarkable Oral phase: – Delay in triggering swallow reflex – Premature spillage Pharyngeal Phase – Incomplete epiglottic inversion – ↓ Tongue base retraction 2° defect – ↓ Laryngeal elevation – ↓ Cricopharyngeal opening – Pharyngeal residue – Inconsistent sensate aspiration during and after the swallow – Effect of Strategies/ Maneuvers/Postures Chin tuck: not beneficial Left head turn: partially beneficial Recommendations/Plan NPO Convert enteral feeding from NG to PEG Enroll & participate in swallowing therapy – ↑ Tongue base retraction – ↑ Laryngeal elevation – ↑ Cricopharyngeal opening – Airway protection exercises 1420_2418Logemann_Jerilyn_A._106563_Nov18_2008_Time_125055PM.doc 9 Treatment Exercises Masako (tongue-hold) – Purpose: Improve tongue base retraction and pharyngeal wall contraction – Evidence: (Lazarus, Logemann, Song, Rademaker, & Kahrilas, 2002; Fujiu & Logemann, 1996) Mendelsohn – Purpose: Increase extent and duration of laryngeal elevation; Increase duration and width of cricopharyngeal opening – Evidence: (Boden, Hallgren, & Witt Hedstrom, 2006; Ding, Larson, Logemann, & Rademaker, 2002; Lazarus, Logemann & Gibbons, 1993; Logemann & Kahrilas, 1990; Dodds, Man, Cook, Kahrilas, Stewart, & Kern, 1988) Shaker Exercise – Purpose: Increase UES opening – Evidence: (Shaker, Kern, Bardan, Taylor, Stewart, Hoffmann, Arndorfer, Hofmann, & Bonevier, 1997; Shaker, Easterling, Kern, Nitschke, Massey, Daniels, Grande, Kazandjian, & Dikeman, 2002; Easterling, Grande, Kern, Sears, & Shaker, 2005) Postural Techniques – Purpose: Redirect bolus flow and change pharyngeal dimensions – Evidence: (Horner, Massey, Riski, Lathrop, & Chase, 1988; Logemann, Kahrilas, Kobara, & Vakil, 1989; Rasley, Logemann, Kahrilas, Rademaker, Pauloski, & Dodds, 1993; Logemann, Rademaker, Pauloski, & Kahrilas, 1994) Medical Treatment (continued) May 2003: – Adjuvant radiation treatment February 2004: – Repeat MBS MBS Results (February 2004) Oral prep: – Unremarkable Oral phase: – Slight delay in triggering swallow reflex – Premature spillage Pharyngeal phase: – Incomplete epiglottic inversion – ↓ Tongue base retraction 2° defect – Slight ↓ Laryngeal elevation – ↓ Cricopharyngeal opening – Pharyngeal residue – Minimal sensate aspiration 1420_2418Logemann_Jerilyn_A._106563_Nov18_2008_Time_125055PM.doc 10 – Effect of Strategies/ Maneuvers/Postures Left head turn: beneficial Recommendations/Plan 100% PO with all consistencies, using a left head turn ¾ LA noted to be noncompliant with using postural techniques Continue swallowing exercises and follow up Medical Treatment (continued) August 2007: – Recurrent SCC of BOT – Partial laryngectomy/total laryngectomy recommended; LA declined October 2007-May 2008: – Receives radiation and chemotherapy at outside facility – Tracheotomy performed secondary to edema – “Failed” multiple swallow studies NPO and had PEG placed No swallowing therapy September 2008: – Returns to our clinic – MBS performed MBS Results (September 2008) Oral prep: – Unremarkable Oral: – Slight delay in triggering swallow reflex – Premature spillage Pharyngeal phase: – Incomplete epiglottic inversion – ↓ Tongue base retraction 2° defect – ↓ Laryngeal elevation – ↓ Cricopharyngeal opening – Pharyngeal residue – Inconsistent sensate aspiration during and after the swallow reflex – Effect of Strategies/Maneuvers/ Postures Left head turn: partially beneficial Left head turn + chin down: beneficial 1420_2418Logemann_Jerilyn_A._106563_Nov18_2008_Time_125055PM.doc 11 Recommendations/Plan Gradually begin oral intake of nectar thick up to semi-solid consistencies with a left head turn and chin down Gradually wean from his PEG tube Re-initiate swallowing therapy – ↑ Tongue base retraction – ↑ Laryngeal elevation – ↑ Cricopharyngeal opening – Airway protection exercises Summary Find what works best for your patient – Be realistic In many cases the anatomy and integrity of muscles and tissues are changed Combination of postural and rehabilitative exercises – Consider quality of life Sometimes you have to reach a compromise Education is key! – Be your patients biggest cheerleader – Involve the family 1420_2418Logemann_Jerilyn_A._106563_Nov18_2008_Time_125055PM.doc 12 Linda Stachowiak, MS, CCC-SLP M.D. Anderson Cancer Center, Orlando, Florida Case Study: Head and Neck patient with complications ¾ 59 yr. old male ¾ T4N2c squamous cell carcinoma of the right base of tongue ¾ Initial treatment: Chemoradiation completed early 2006 ¾ PEG placed prophylactically ¾ Speech Pathology Pre-treatment clinical swallowing evaluation and education not done (treated elsewhere) Case study ¾ Residual disease treated with sx at another institution 3/13/06: right lateral pharyngeal wall, right modified neck dissection and pectoralis myocutaneous flap reconstruction ¾ First MBS done at same facility as sx, significant for aspiration per patient, recommended for tx; however pt unable to travel the distance to the facility ¾ Home Health SLP services recommended; however, never scheduled per patient ¾ First seen at our facility 9/14/06: – Tongue deviation to the right with atrophy – Significantly reduced strength and ROM of the tongue on the right – Surgical defect of right soft palate and right lateral pharyngeal wall – Moderate hypernasality with nasal emission – Fiberoptic Endoscopic Evaluation of Swallowing (FEES) study completed FEES results Questionable area noted upon scoping, requiring MD evaluation Good instrumental tool to assess deviations in anatomy Poor instrumental tool to comprehensively assess the physiology of the swallow due to the severity of the deficits Modified Barium Swallow Study planned Initial MBS results Oral transit functional with liquids – required slight head tilt to assist in transfer posteriorly Repetitive AP lingual stripping with puree which slowed oral transit but overall functional with no significant oral residue No masticated consistencies provided due to edentulous state Reduced VP closure but no nasal regurgitation Reduced hyolaryngeal elevation 1420_2418Logemann_Jerilyn_A._106563_Nov18_2008_Time_125055PM.doc 13 Reduced BOT retraction towards PPW Reduced epiglottic inversion Penetration of all consistencies Trace silent aspiration after the swallow Residue in valleculae and pyriform sinuses increased as the consistency increased Liquid residue cleared with subsequent dry swallow Puree residue cleared with a liquid wash Aggressive swallowing therapy recommended Treatment Plan Super-supraglottic swallow maneuver Effortful Swallow Mendelsohn Maneuver Tongue- holding maneuver Shaker Exercise Oral trials with above strategies Super-supraglottic maneuver ¾ Place the bolus in the oral cavity ¾ Hold your breath while bearing down (like you are going to the bathroom) ¾ Swallow ¾ Cough immediately after the swallow Purpose: Volitional airway protection (holding breath brings TVC’s together, bearing down increases airway protection by increasing tilting of the arytenoids and retraction of the BOT, cough redirects any penetrants or aspirants) Effortful swallow ¾ Swallow normally, but squeeze hard with your tongue muscles and “throat” muscles throughout the swallow Purpose: improve tongue base retraction and reduce residue in the valleculae after the swallow Mendelsohn maneuver ¾ Swallow normally ¾ Feel your “voice box” or Adam’s apple lift during the swallow ¾ On the next swallow, hold the “voice box” up with your neck muscles for several seconds during the swallow ¾ When you feel your “voice box” go up, grab it with your neck muscles and don’t let it down Purpose: To accentuate and prolong laryngeal elevation and anterior movement, increasing the extent and duration of the cricopharyngeal opening 1420_2418Logemann_Jerilyn_A._106563_Nov18_2008_Time_125055PM.doc 14 Tongue holding maneuver ¾ Put your tongue between your teeth (or gums if edentulous) ¾ Swallow ¾ If the patient can’t protrude the tongue out of the mouth, have him try to push it behind the teeth and gradually attempt to protrude it further from the mouth Purpose: Exercise the glossopharnygeal muscle and improve BOT to PPW retraction Shaker exercise ¾ ¾ ¾ ¾ ¾ ¾ Lay flat on your back on the bed or floor. Raise your head and look at your toes for one minute. Do not raise your shoulders off the bed or the floor as you raise your head. Lay your head flat and rest for one minute. Repeat this sequence a total of three times. The amount of time you hold your head up should be the same as the amount of time you rest. At first you may only be able to hold it up for 5 secs…then you should rest it for 5 secs. Until you can build up to one full minute. ¾ Next raise your head thirty times consecutively without holding it. Again, do not raise your shoulders while looking at your toes. ¾ Once again, you may need to gradually build up to thirty times. ¾ Do the entire exercise three times per day for six weeks. Purpose: The Shaker exercise, was developed to increase upper esophageal sphincter (UES) opening. It is based on the fundamental principle that the UES opening is a mechanical event, consisting of a series of external forces applied to the UES combined with relaxation of the sphincter musculature. Complications/Issues Significant deficits to begin with Lengthy time frame between surgery, first MBS and initiation of swallowing therapy Limited educational level of patient Questionable patient motivation: o Religiously attended therapy; however: o Limited home practice of both exercises and PO trials as instructed Patient told that he must be committed to program or else can’t continue with attending therapy sessions Break in intervention SLP contacts patient after 3 months, states that he “is ready” Patient becomes committed to working on home practice as instructed by SLP Making great gains Begins weaning from PEG tube feeds Working jointly with dietician to wean patient….getting realistically close to goal of removing tube 1420_2418Logemann_Jerilyn_A._106563_Nov18_2008_Time_125055PM.doc 15 Patient noted to have a suspicious lesion on his cheek Basal cell lesion diagnosed Patient has lesion surgically removed No SLP intervention for several weeks Patient backslides with PO intake Swallowing therapy resumed Patient agrees to follow through with home program Repeat modified barium swallow study Repeat MBS results Pt continues with moderate to severe pharyngeal dysphagia BUT with improvement in airway protection. This allows patient to use aggressive compensatory swallowing strategies in order to swallow liquid and puree consistencies safely. Goal: partial PO nutrition with reduced PEG tube feedings due to chronic severe dysphagia Final outcomes ¾ ¾ ¾ ¾ Patient resumes complete PO nutrition All medications PO Maintains weight for one month, no PEG use PEG tube removed! Key points to ponder Therapy goal was not functional restoration, all COMPENSATORY Patients may not always be motivated when we are! No Practice = no gains Practice= gains! A break in treatment not always seen in a positive light, but may be what some folks need. There may be a window for functional restoration but not necessarily in compensatory restoration as this case points out! 1420_2418Logemann_Jerilyn_A._106563_Nov18_2008_Time_125055PM.doc 16 Bernice K. Klaben, Ph.D. CCC-SLP, BRS-S University of Cincinnati, Department of Otolaryngology The Person 44 yr old female Hair stylist/nail tech Two teenage girls Married Supportive family Active Medical History Hx of smoking 1 ½ ppd x 25 yrs, No ETOH abuse 2006 Sept dx T2N2MO SCCa R aryepiglottic fold & medial R pyriform sinus 2006 Oct to 2007 March concurrent chemoradiation PEG secondary to XRT related dysphagia 20 lbs weight loss Throat soreness/odynophagia (started July 2007) Hoarseness (started Aug 2007) History of heartburn Medications Protonix 2 x daily Requip Lexapro Ambien Iron supplement Referred to Univ of Cincinnati ENT Specialists (Oct 2007) Confirmed chemoradiation failure R ear pain Recurrent CA – poorly differentiated SCCa Vocal folds mobile Moderate edema bilateral arytenoids and epiglottis Surgery (Oct 2007) Tracheotomy Supraglottic laryngectomy Post Surgical Pharyngocutaneous fistula became persistent Poor healing (neck edema/facial edema) Referred for HBO (initial Nov 07) Decanulated (12-07-07) following 17 treatments Referred for voice & swallowing eval (Dec 2007) 1420_2418Logemann_Jerilyn_A._106563_Nov18_2008_Time_125055PM.doc 17 Hyperbaric Chamber Received 60 dives (b/t Nov 07 to Feb 08) Tissue termed “Triple-H” – Hypo-vascular – Hypo cellular – hypoxic Increases the pressure of O2 in surrounding chamber allowing for greater absorption of O2 in all body tissues Evaluation Neck/facial edema Limited head/neck ROM Fibrosis of neck (digastric, supra-hyoid)/scarred tracheal area Poor posture (chin down) Severely restricted laryngeal elevation Restriction of jaw opening Decrease lingual ROM and strength Severe dysphonia (wet vocal quality) Audible inhalation (increased edema) Increased thick mucus Mild xerostomia Treatment Voice exercises (sustain phonation w/kazoo) Lingual ROM and Strengthening Head ROM Swallowing exercises – Supraglottic swallow – Breath hold – Suck swallow – 1 to 2 ml of water trials with syringe Humidification Received PT (Flexion/Extension, Manual therapy) Progress Sustain phonation 2 secs to 7 secs/vocal range improved (161 Hz to 237 Hz) Noted improvement in vocal quality Management of secretions Improved laryngeal elevation Supraglottic swallow – 2 ml of water Improved cervical ROM 1420_2418Logemann_Jerilyn_A._106563_Nov18_2008_Time_125055PM.doc 18 Improved subcutaneous tissue mobility Decreased pain Set Back Increased dysphagia (March 2008) – “feels like my neck is tight and swollen” Increased dypnesa PET/CT – hypermetabolic activity in R lobe of thyroid, R jugular neck node Surgical biopsies, dilatation of cervical esophagus to 50FR Maloney FNA – positive for SCCa Surgery 2008 May – R RND with R pectoralis major myofascial flap – Removal of jugular vein – Sacrificed spinal accessory nerve – Tracheotomy Biopsy result – Soft tissue disease measuring 3 cm in size Current Treatment Chemotherapy – Palliative – Response rate in irradiated field 30-35% – Taxotere, carboplatin, & 5-FU, Erbitux Pain management Able to communicate with occlusion of trach Able to manage secretions Continues to do some of the swallowing and voice exercises Awaiting next PET/CT scan 1420_2418Logemann_Jerilyn_A._106563_Nov18_2008_Time_125055PM.doc 19 Amy Kelly, MA, CCC-SLP NorthShore University HealthSystem, Evanston, Illinois Initial Presentation 57 y/o male 30 yr h/o tobacco use (quit 2000); daily ETOH use s/p CABG 2000 L carotid occlusion s/p stent 2003 L base of tongue mass (SCCA) resected 2001 at an outside facility Resection included partial mandibulectomy with partial fixation Further treated with chemoradiation (not clear at what level/protocol) Follow up via serial CT scans – unremarkable until 2007 Pt developed oozing and pain from R mandible 2007 after molar extraction 2007 scan revealed R mandibular osteonecrosis Asymmetry/soft tissue prominence of the R posterior floor of mouth, genioglossus, hyoglossus and pterygoid muscles – further w/u revealed post-operative changes vs. recurrence of disease Pt was treated with hyperbaric oxygen and antibiotics for acute infection and mandibular osteoradionecrosis 4/08 developed severe trismus; recommendation is for osteitic bone and fibular microvascular free tissue reconstruction Pt also developed dysphonia Videostroboscopic findings by SLP were decreased abduction of the TVCs bilaterally; significant edema of the endolarynx and epiglottis consistent with radiation changes Pt underwent R mandibular ramus reconstruction with osteocutaneous R fibular free flap to R oral/mandibular buccal sulcus; performed by maxillofacial surgeon and plastic surgeon 5/08 Postoperatively; pt demonstrated decreased mental status and L hemiplegia Workup revealed R occipital stroke Decision Making Process for Therapy Plan Problem 1: pt unable to take any nutrition orally Problem 2: pt unable to verbally communicate Factors impeding treatment for both problem 1 and 2 – Decreased cognition due to R occipital stroke – Minimal jaw opening due to trismus 1420_2418Logemann_Jerilyn_A._106563_Nov18_2008_Time_125055PM.doc 20 Acute Rehabilitation One week postoperatively, transferred to acute rehabilitation unit at Evanston Hospital Pt was 95% unintelligible; h/w full oral-motor exam was not possible due to severe trismus Difficulty with secretion management; unable to deep suction due to trismus Pt attempted to communicate via writing; however limited due to severe L hemiinattention and visual-spatial deficits Patient presented with moderate cognitive-linguistic deficits characterized by decreased attention, impulsivity, concrete reasoning Patient demonstrated premorbid psychological issues (anxiety, need for control) which interfered with participation in therapy initially Acute Rehabilitation Trismus Trismus had to be dealt with as primary goal for speech and swallowing Initially, mandibular excursion was not adequate for insertion of Therabite Followed Therabite protocol (7/7/7) with gentle jaw ROM exercise Progressed to using tongue blade as a bite block/target goal for opening Systematically added tongue blades as mandibular ROM increased When pt reached 10-15 mm. of opening, Therabite was initiated When mandibular excursion adequate for lingual examination; pt’s wife indicated that R hypoglossal nerve had been “cut” No lingual movement bilaterally; tongue was completely flaccid with atrophy beginning to be evident Trismus Therabite measuring scale 1420_2418Logemann_Jerilyn_A._106563_Nov18_2008_Time_125055PM.doc 21 Acute Rehabilitation Dysphagia Pt was kept strict NPO postoperatively Initially fed via DHT; PEG inserted prior to transfer to rehabilitation unit Pt underwent VFS approximately 2 weeks postoperatively (could not fit syringe into oral cavity prior to that time) VFS revealed severe oropharyngeal dysphagia; pt inconsistently bit down on syringe due to cognitive deficits Administered 3 ml thin liqs via syringe Copious anterior spillage due to inability to propel or control bolus After passive spillage to pharynx, swallow was initiated with decreases in strength of all pharyngeal events (BOT retraction, elevation of hyolaryngeal complex and A-P vestibule closure) Trace aspiration occurred after the swallow due to pharyngeal residue; pt unable to clear with cued cough Swallow rehabilitation initiated 3 sets, 10 repetitions of BOT retraction exercises, laryngeal elevation including Shaker, and effortful breath hold ex for vestibule closure Pt continued to require maximum cues due to cognitive deficits Managed secretions via frequent Yankur suction Thorough oral care provided and supervised by RN, albeit difficult due to trismus Follow up VFS in 2 weeks revealed slight improvement Pt tolerated small sip (2-3ml) via medicine cup with head tilt L and then back; better passive control than via syringe Continued to demonstrate significant pharyngeal dysphagia and aspiration; SSGS attempted but unsuccessful due to cognitive deficits Recommendation was continued NPO with trials with speech only to train on SSGS Pt did not attempt verbal communication, but wrote on a dry erase board Written expression characterized by decreased linear formation, L neglect and decreased attention to detail which negatively impacted legibility of message Acute Rehabilitation Communication Trained pt to continue to attempt to verbalize all messages Utilized dry erase board with alphabet for indicating initial sound and clarifying responses 1420_2418Logemann_Jerilyn_A._106563_Nov18_2008_Time_125055PM.doc 22 Outpatient Rehabilitation The patient was at a great geographical distance from our facility (+50 miles) Came in for 3 sessions at our outpatient voice lab Attempted to train him on the SSGS using nasal endoscopy for biofeedback Pt unable to sequence SSGS despite multiple attempts due to his cognitive deficits Outpatient Rehabilitation Trismus Mandibular excursion at the beginning of outpatient treatment was 20-25 mm. Continued therapy program with Therabite (7/7/7 protocol) as a home program Outpatient Rehabilitation Dysphagia Reviewed and updated home program of dysphagia exercises – Masako maneuver – Mendelsohn maneuver – BOT exercises – Laryngeal elevation exercises – Shaker exercise – Added lingual resistance exercise with tongue blade in an attempt to stimulate regeneration Outpatient Rehabilitation Current Status Pt began seeing an SLP closer to his home following our treatment plan Taking small amounts (3-5ml) liquids via medicine cup up to 5 trials/3x per day Good tolerance to date, no PNAs Continuing to try SSGS sequencing, as theoretically pt would be able to increase oral intake if successful 1420_2418Logemann_Jerilyn_A._106563_Nov18_2008_Time_125055PM.doc 23 Jeri A. Logemann, Ph.D., CCC-SLP, BRS-S Northwestern University, Evanston, Illinois Patient ¾ Patient was a 46-year-old man ¾ Suffered a salivary gland malignant squamous cell tumor removed with reportedly no effect on swallowing ¾ 2 years later, he suffered a recurrence ¾ Second surgery in the same region did result in severe dysphagia and unilateral facial weakness At the time of initial evaluation: ¾ Small diameter nasogastric tube in place at the time of his evaluation and used for his nutritional intake since his second surgery 6 weeks earlier ¾ Visible droop of the left corner of his lips ¾ Regular loss of saliva ¾ Oral control revealed mild left lingual weakness ¾ Moderate difficulty in reaching the left lower sulcus ¾ Oral tongue on the left was weak when tested against resistance. At the time of the initial MBS evaluation: ¾ Modified barium swallow revealed some difficulty in controlling liquid boluses in his mouth ¾ Pharyngeal swallow triggered well 1420_2418Logemann_Jerilyn_A._106563_Nov18_2008_Time_125055PM.doc 24 ¾ When the pharyngeal swallow triggered most severe swallowing disorders exhibited themselves ¾ Nasogastric tube in place ¾ Severely reduced laryngeal and hyoid elevation ¾ Reduced upper esophageal sphincter opening ¾ Residue after the swallow and aspiration after the swallow ¾ Head rotation did contribute to improved but far from normal swallow. Other exercises were needed At the time of the initial MBS evaluation The following treatments for this patient’s swallowing disorders were introduced: ¾ head rotation in an attempt to redirect food down the slightly stronger side of the pharynx ¾ tongue base exercises – gargle, pull tongue base back, yawn ¾ Mendelsohn maneuver ¾ Shaker exercise ¾ patient instructed to practice these exercises 10 times a day, 5 minutes each time ¾ Given exercises for laryngeal elevation including the falsetto exercise involving sliding upscale as high as possible ¾ Instructed to use his hand as an assist and to pull up gently on his thyroid cartilage as he did the sliding scale exercise. o This should not be done during swallow as the hand may interfere with the swallow 1420_2418Logemann_Jerilyn_A._106563_Nov18_2008_Time_125055PM.doc 25 ¾ Taught the super-supraglottic swallow to increase duration of airway closure ¾ Given no food or liquid At the fourth therapy session ¾ At the fourth session patient again exhibited not only the ability to do his exercises without looking at any instructions but to do them with greater apparent range of motion. ¾ Additional exercises for his facial weakness, including spreading the lips, rounding the lips, and resistance against lip closure with tongue blades. At the fourth therapy session, 2nd MBS ¾ At this session, the patient was able to increase the pitch with great success, all the way into falsetto ¾ Second modified barium swallow using his super-supraglottic swallow and head rotation to the left ¾ Capable of swallowing the bolus successfully. ¾ He did have to repeat swallow 3 to 5 times to clear the residue after the swallow 4 weeks later ¾ This MBS reveals better laryngeal lifting and anterior movement with the head rotated to one side. ¾ Much less residue, ¾ Patient is aware of the residue ¾ Ready to attempt some oral intake on thin liquids 1420_2418Logemann_Jerilyn_A._106563_Nov18_2008_Time_125055PM.doc 26 4 weeks later ¾ A month later, the patient is beginning full oral intake on thin and thick liquids and soft foods. ¾ Head rotation improved the swallow at this time but is not continually necessary. 2 weeks later ¾ Patient had spontaneously begun to take swallows of small amounts of liquid with his head turned, using his super-supraglottic technique. ¾ Stopped taking 3 cans of Ensure at lunch, replacing them with oral intake on soup. ¾ He was again reminded that the purpose of the exercises was to return him to oral intake but not to achieve a certain amount of oral intake at this time. Final modified barium swallow: ¾ Tested with all food consistencies: thin liquids, thick liquids, pudding and masticated material ¾ Small amounts of residue in the pharynx ¾ Repeat swallows were used to clear the residue ¾ Patient was warned to call should he have any perceived changes in his swallow or in chest congestion. 1420_2418Logemann_Jerilyn_A._106563_Nov18_2008_Time_125055PM.doc 27 Presenters Angela Campanelli, MS, CCC-SLP, is the Clinical Specialist of Dysphagia at Kettering Hospital, a part of Kettering Health Network, in Dayton, Ohio. She is a Board Recognized Specialist in Swallowing and Swallowing Disorders with over 20 years experience in adult dysphagia therapy, specializing in treatment of Head and Neck Cancer. She has taught in the area of swallowing at Grand Rounds, peer in-services, and state and national conventions. She contributed to data collection for Dr. Logemann, for the “Effects of Swallowing Therapy on Head and Neck Cancer”. Amy Kelly, MA, CCC-SLP, is a senior staff member and manager of the speech pathology department at NorthShore University HealthSystem, Illinois. Her clinical practice has focused on the areas of adult neurogenics, head and neck cancer, and dysphagia in infant through adult populations. Bernice Klaben, Ph.D. CCC-SLP, BRS-S is an associate professor in the Department of Otolaryngology Head and Neck Surgery at the University of Cincinnati. She co-authored Clinical Voice Pathology: Theory and Management. Dr. Klaben specializes in voice disorders, laryngectomy voice restoration, paradoxical vocal cord dysfunction, dysphagia in neurogenic and head and neck patients. Mario A. Landera, MA, CCC-SLP is currently working at the University of Miami Miller School of Medicine in the department of Otolaryngology. His practice is limited to head and neck cancer rehabilitation and voice disorders. Mario received his Master's degree in Communication Sciences and Disorders from the University of Florida. Jeri Logemann, PhD, CCC-SLP, BRS-S is Ralph and Jean Sundin Professor of Communication Sciences and Disorders at Northwestern University, and Professor of Otolaryngology and Maxillofacial Surgery and Neurology at Northwestern University Medical School. She has published and lectured widely both nationally and internationally on evaluation and treatment of swallowing disorders. Donna S. Lundy, PhD, is an associate professor in the Department of Otolaryngology at University of Miami Miller School of Medicine. She specializes in the care and management of individuals with head and neck cancer, dysphagia, and voice disorders. Dr. Lundy actively participates in a number of multi-institutional research grants. 1420_2418Logemann_Jerilyn_A._106563_Nov18_2008_Time_125055PM.doc 28 Linda Stachowiak, MS, CCC-SLP BRS-S, is a Speech Pathologist at the MD Anderson Cancer Center, Orlando, Florida and adjunct instructor at the University of South Florida. She is also a CAA site visitor for ASHA and frequent presenter at state and national conferences. She has extensive clinical experience in dysphagia and head and neck cancer and tracheostomized and ventilator dependent patients. She also participates in multi-institutional research which investigates functional outcomes in the areas of speech and swallowing with head and neck cancer patients. She is a Board Recognized Specialist in Swallowing and Swallowing Disorders. 1420_2418Logemann_Jerilyn_A._106563_Nov18_2008_Time_125055PM.doc 29
