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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 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 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 Change swallow physiology Exercises and maneuvers Compensatory treatment procedures Introducing postures head back, chin down, head tilt, head rotation toward the weak side, lying down Adjusting bolus volume and consistency Intraoral prosthetics 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 Supraglottic swallowing Super-supraglottic swallow Effortful swallow Mendelsohn maneuver Reference 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 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