Download Swallowing disorder in head and neck cancer patients

Swallowing disorder in head
and neck cancer patients
R3吳俊璟
2007/07/25
Normal swallowing
Oral preparation phase
Structure
Afferent
Lip
V2(maxillary),V3(li VII
ngual)
closure
Tongue
V3(lingual)
XII
Lateral rolling
movement
Mandible
V3(mandibular),
V(muscles of
mastication),
VII
Chewing, rotary
motion
Palate
V,IX,X
IX,X
Soft palate bulging
forward
V(muscles of
mastication),
VII
Tension in the labial
and buccal muscles
Buccal region
/cheeks
Efferent
Function
Oral transport phase
„
„
<1~1.5 sec
Moving food bolus from oral cavity to
pharynx
„
„
„
Posterior tongue depressed
Anterior/middle tongue elevate
Trigger pharyngeal phase:
glossopharyngeal nerve at the level of
tongue base
Pharyngeal phase
„
„
„
< 1 sec
Velopharyngeal closure
Closure of the airway
„
„
„
„
Elevation of hyoid and larynx
Larynx closure: true and false folds, AE fold
Relaxation of cricopharyngeal muscle
Push the food through the pharynx
„
Tongue base and pharyngeal wall
Cranial nerves to pharyngeal phase
Structure
Afferent
Efferent
Tongue base
IX
XII
Epiglottis(lingual side)
IX
X
Epiglottis(laryngeal side)
X (int. branch of superior
laryngeal nerve)
X
Larynx (above true fold)
X (int. branch of superior
laryngeal nerve)
X
Larynx (below true fold)
X (recurrent laryngeal nerve) X
Pharynx (naso-and oro-)
IX
X(stylopharyngeus
ÆIX)
Pharynx (hypopharynx)
X (int. branch of superior
laryngeal nerve)
X
Esophageal phase
„
„
8~20 sec
Primary peristalsis
„
„
Swallow induced peristaltic activity
Secondary peristalsis
„
Initiation of a propagated contraction wave
in the absence of a swallow
Evaluation of dysphagia
„
„
„
„
History
Clinical evaluation
Instrumental examination
Patient self-assessment
„
„
„
SWAL-QOL:44 item
SWAL-CARE: 15 item
MD Anderson Dysphagia Inventory(MDADI)
Fiberoptic endoscopic
examination of swallowing (FEES)
„
„
„
„
A spoonful of pudding (3 ml)
Hold the bolus in his mouth
for ~10 s.
The procedure was
terminated once aspiration
occurred.
Another three bouts of 3 ml
of diluted green food color
dye were administered to
subjects who safely passed
the above examination.
Methods for measuring
swallowing function
Defines
Detect
Quantifies Detect Availability Cost
anatomy aspiration aspiration etiology
BSE
-
+/-
-
+/-
++
1
FESS
++
+
-
+
++
2
FEESST
++
++
-
++
+
3
MBS(VFS)
+
++
+
+
+
4
Ultrasound
+/-
-
-
-
+/-
5
Manometry
-
+/-
-
+
+
6
Swallowing Performance Scale
„
„
„
„
„
„
„
Grade 1 Normal.
Grade 2 Within functional limits: abnormal oral or pharyngeal stage but
able to eat a regular diet without modifications or swallowing precautions.
Grade 3 Mild impairment: mild dysfunction in oral or pharyngeal stage
requires a modified diet without need for therapeutic swallowing precautions.
Grade 4 Mild-to-moderate impairment with need for therapeutic
precautions: mild dysfunction in oral or pharyngeal stage, requires a
modified diet and therapeutic precautions to minimize aspiration risk.
Grade 5 Moderate impairment: moderate dysfunction in oral or
pharyngeal stage, aspiration noted on exam, requires a modified diet, and
swallowing precautions to minimize aspiration risk.
Grade 6 Moderate–severe dysfunction: moderate dysfunction of oral or
pharyngeal stage, aspiration noted on exam; requires a modified diet and
swallowing precautions to minimize aspiration risks; needs supplemental
enteral feeding support.
Grade 7 Severe impairment: severe dysfunction with significant aspiration
or inadequate oropharyngeal transit to esophagus, nothing by mouth, requires
primary enteral feeding support.
Head and neck cancer induced
swallowing dysfunction
„
„
„
„
„
Mechanical obstruction
Decreased pliability of the soft tissue
Direct invasion leading to paralysis of
important muscles
Loss of sensation due to nerve injury
Pain
Swallowing function in head and
neck cancer prior to treatment
„
Patients with hypopharyngeal and laryngeal
cancer: more aspiration, high percentage of
pharyngeal and esophageal impairment
Swallowing abnormalities
following chemoradiation
„
Xerostoma
„
„
„
Decreased bolus lubrication
Increased bolus transit time
Affect neuromuscular mechanismÆ fibrosis,
neuropathy, myelopathy
„
„
„
„
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Reduction of posterior tongue movement
Reduced tongue strength
Increased oropharyngeal transit time
Reduced laryngeal /hyoid movement
Increased pharyngeal residue
Abnormal esophageal sphincter function
Aspiration
Morbidities of dysphagia
„
„
„
„
Poor oral intake, body weight loss,
Tube feeding dependent, decreased
quality of life
Depression, anxiety
Silent aspiration and aspiration
pneumonia
Dysphagia in NPC patients
after radiotherapy
„
„
„
„
Most common deglutition problemÆ
pharyngeal retention
Intact vocal cord functionÆ
prerequisite for not aspirating
Multiple dysfunctions
Not related to radiation dose and
staging
Swallowing abnormalities after
CCRT according to videofluoroscopy
Chronic dysphagia and
aspiration following CCRT
Aspiration after treatment
Molecular biology of tissue damage
induced by chemoradiation
„
„
Radials interact with cell DNAÆ
hyperactivation of transforming growth
factor beta-1(TGF-β1)Æ increased
collagen production and inhibition of its
degradationÆ scar formation and
decreased perfusion and oxygenation
Elevated TGF-β1 in patient with severe
mucositis and late complication
Swallowing dysfunction after
surgery
„
Swallowing problems depend on
„
„
„
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Extent of the resection
Specific structure resected
The nature of reconstruction
Primary closure results in better
swallowing function
Post-op RT effect manifest >6 months
Strategies to decrease
swallowing disorders
„
„
„
RT beam modulation: IMRT
Amiofostine: cytoprotective agent, for
xerostomia, no data on swallowing
Range of motion exercise
„
„
Oral tongue, tongue base, lips, larynx, hyoid
related musculature
Resistance exercise
„
Strengthening exercise and involve stretching the
target structure and holding it in extension
Rehabilitation strategies
„
Compensatory treatment procedures
„
„
„
Control the flow of the bolus
Reduce or eliminate aspiration
Treatment technique
„
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Change swallow physiology
Exercises and maneuvers
Compensatory treatment
procedures
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Introducing postures
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„
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head back, chin down, head tilt, head
rotation toward the weak side, lying down
Adjusting bolus volume and consistency
Intraoral prosthetics
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Maxillary reshaping prosthesis
Obturators
Therapy exercise
„
Shaker exercise:
„
„
„
cricopharyngeal dysfunction
Lay flat on the floor and hold the head off
the floor looking at the feet for 1 min
Range of motion and resistance
exercise
Swallow Maneuvers
„
„
„
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Supraglottic swallowing
Super-supraglottic swallow
Effortful swallow
Mendelsohn maneuver
Reference
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David I. Rosenthal, et.al. Prevention and Treatment of Dysphagia and Aspiration After Chemoradiation
for Head and Neck Cancer J Clin Oncol 24:2636-2643, 2006
Bharat B. Mittal, et. al. Swallowing dysfunction—preventive and rehabilitation strategies in patients
with head-and-neck cnacers treated with surgery, radiotherapy, and chemotherapy: a critical review
Int. J. Radiation Oncology Biol. Phys., Vol. 57, No. 5, pp. 1219–1230,2003
Nam P. Nguyen, et .al. Dysphagia following chemoradiation for locally advanced head and neck cancer
Annals of Oncology 15: 383–388, 2004
Nam P. Nguyen, et. al. Evaluation and management of swallowing dysfunction following
chemoradiation for head and neck cancer Current Opinion in Otolaryngology & Head and Neck Surgery
15:130–133, 2007
David I. Rosenthal, ET. AL. Prevention and Treatment of Dysphagia and Aspiration After
Chemoradiation for Head and Neck Cancer J Clin Oncol 24:2636-2643. 2006
Kerstin.M stenson, et.al. Swallowing function in patients with head and neck cancer prior to treatment
Arch otolaryngol head neck surg.126:371-377, 2000
Hong-Wen Chen et.al. Change of Plasma Transforming Growth Factor-b1 Levels in Nasopharyngeal
Carcinoma Patients Treated with Concurrent Chemo-radiotherapy Jpn J Clin Oncol;35(8)427–432, 2005
Chin-shin Wu et.al. Dysphagia after radiotherapy: endoscopic examination of swallowing in patients
with nasopharyngeal carcinoma Ann otol Rhinol Laryngol 109: 320-325, 2000
Thomas Murry, Ricardo L. Carrau Clinical management of swallowing disorders second edition, San
Diego, plural publishing, Inc.2006
Nam P. Nguyen, et .al. Dysphagia severity following chemoradiation and postoperativeradiation for
head and neck cancer, European Journal of Radiology 59 453–459, 2006