Download Swallow Preservation Protocol - California Speech

Using Evidence Based Practice to Build a Head
and Neck Cancer Program
• Submission Number: 0687-000191
• Disclosure:
• No relevant financial or non-financial
relationship exits for this talk.
Building a Swallow Preservation
Protocol For Patients With
H&N Ca
Maria Cordova, MS, CCC-SLP
Kimberly Dias, MS, CCC-SLP
Paul McRae, MA, CCC-SLP
Overview:
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General H &N Ca information
Tumor sites
Tumor Node Metastasis (TNM) Staging System
World Health Organization (WHO) typing of tumors system
Background for creating swallow preservation protocol (SPP)
Development of SPP
Overview of SPP
SPP study Outcomes/Implications
Where to go from here?
Head and Neck Cancer Statistics
• Cancers of the H&N: oral cavity/larynx/pharynx/salivary glands/nose
• Standard tx include: RT, CT, a combo CRT, and surgery
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H&N Ca account for approx. 3% of all malignancies in US
5th most common Ca in US
50,000 new H&N Ca cases per year in US
20,000 deaths per year in US
• Overall incidence began decreasing 30 years ago, stabilized in 2003
• Whereas overall mortality rates have steadily declined
Head and Neck Ca Risk Factors
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Old Guard:
Tobacco intake alone = increases risk
Alcohol intake alone = mildly increases risk
Tobacco and alcohol intake together = significant increased risk
• New Guard:
• Human papillomavirus (HPV P16+) > ½ of all oropharyngeal Ca cases
• 225% increase in HPV P16+ oral pharyngeal Ca
• HPV is sexually transmitted w increasing risk of:
• # of sexual partners
• First intercourse < or = 17 y/o
• Reduced use of condoms
Tumor Sites
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A majority of H&N Ca tumors arise from squamous mucosa that lines the upper
aerodigestive track and are predominantly squamous cell carcinomas.
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Upper aerodigestive track anatomic subsites include:
Oral cavity
Tumor Sites
Oropharynx
Tumor Sites
Hypopharynx
Tumor Sites
Larynx
Tumor Sites
Nasopharynx
Tumor Sites
Nose and Paranasal Sinuses
Head and Neck Lymph Node System
Head and Neck Lymph Node System
Tumor Sites: Oral Cavity
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Oral Cavity Sub-sites: lips, anterior tongue, floor of mouth, buccal mucosa,
upper/lower alveolar ridges, hard palate and retromolar trigone
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Lymph node spread: to lymph nodes of submandibular region and upper/middle
jugular chain lymph nodes
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Treatment: mandible and maxilla bone structures preclude using RT due to
radionecrosis, primary tx is surgical
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Positive surgical margins, and/or multiple lymph node involvement may call for
postoperative CRT to improve local disease control.
Take Home Message: Oral Cavity Ca= surgery w CRT only if unable to resect whole
tumor
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Tumor Sites: Oropharynx
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Oropharynx Sub-sites: tonsil, base of tongue, soft palate, pharyngeal walls
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Lymph node spread: metastasize to upper/middle jugular chain lymph nodes, but
may also spread to retropharyngeal lymph nodes
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Treatment: complex depending on how advanced the disease is
RT alone and/or CRT may be utilized
NOTE: Some of these cancers are associated with HPV P16 +.
Increased incidence of HPV 16+ in 30-50 y/o men, vaccine Gardisol.
Tumor Sites: Hypopharynx
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Hypopharynx Sub-sites: pyriform sinuses, post cricoid region, pharyngeal walls
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Lymph node spread: metastasize to upper, middle, and lower jugular lymph nodes
and retropharyngeal nodes
often advanced and difficult to cure
location can impact swallowing/speech
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Treatment: surgery, CRT
Tumor Sites: Larynx
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Larynx Sub-sites: supraglottic, glottis, and subglottic areas
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Lymph node spread: metastasize to the upper, middle, and lower jugular chain
lymph nodes
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Treatment: tx for laryngeal cancers variesEarly stage lesions RT or transoral endoscopic excision are common
Later stage lesions laryngectomy was standard for T3 and T4 larynx Ca.
CRT also effective for achieving local regional control, survival, and organ
preservation.
Tumor Sites: Nasopharynx
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Nasopharynx: bounded by choanae at back of nose, roof and posterior walls of
nasopharynx, inferiorly, at level of soft palate, nasopharynx meets the superior
oropharynx
Note: Eustachian tube impingement may manifest in hearing loss particularly in
areas where NPC is endemic (southern China, northern Africa, Greenlandcarcinogenic volatile nitrosamines in diet-salted fish).
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Lymph node spread: metastasize to retopharyngeal and parapharyngeal lymph
nodes, along the upper, lower, and middle jugular chains
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Treatment: Early detection = RT alone
more advanced cases T3/4 N+ = concomitant CRT is utilized
surgery rare in salvage situations at primary site or neck
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Nose and Paranasal Sinuses: SLP no role
TNM Staging of H&N CA and Neck Dissection
Classification
TNM = Tumor Node Metastasis staging system
• Categorizes tumors to help assess disease status/prognosis/management
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All clinical information used in staging =
physical exam/radiographic studies/intraoperative reports/pathologic
findings/histopathologic analysis
TNM Staging of H&N CA and Neck Dissection
Classification
Three categories TNM system:
• T- (Tumor) characteristics of tumor at primary site
• (e.g. size, location)
• Where/how big is primary tumor?
TNM Staging of H&N CA and Neck Dissection
Classification
• N- (Node) degree of regional node involvement
• Has tumor spread to lymph nodes?
TNM Staging of H&N CA and Neck Dissection
Classification
• M- (Metastasis) absence or presence of distant metastases
• Has Ca metastasized to other body parts?
TNM Staging of H&N CA and Neck Dissection
Classification
TNM Staging of H&N CA and Neck Dissection
Classification
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Head & Neck TNM Staging
By William Guy
Open iTunes to buy and download apps.
Description
This app is designed to help people with
head and neck cancer staging. It is set up
in an intuitive way to help you come to
the final stage. Each tab has the
appropriate descriptions for the
respective T stage and nodal status.
To test your knowledge there is a quiz
section with over 20 different clinical
vignettes.
This app is designed for both iPhone and
iPad
$1.99
Category: Medical
Version: 1.0
Size: 3.3 MB
Language: English Rated 4+
Compatibility: Requires iOS 4.3 or later.
Compatible with iPhone, iPad, and iPod
touch
TNM Staging of H&N CA and Neck Dissection
Classification
Table 1. Primary Tumor (T)a
TX
Primary tumor cannot be assessed.
T0
No evidence of primary tumor.
Tis
Carcinoma in situ.
T1
Tumor ≤2 cm in greatest dimension.
T2
Tumor >2 cm but ≤4 cm in greatest dimension.
T3
Tumor >4 cm in greatest dimension or extension to lingual
surface of epiglottis.
T4a
Moderately advanced local disease. Tumor invades the larynx,
extrinsic muscle of tongue, medial pterygoid, hard palate, or
mandible.b
T4b
Very advanced local disease. Tumor invades lateral pterygoid
muscle, pterygoid plates, lateral nasopharynx, or skull base, or
encases carotid artery.
AJCC: Pharynx. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010,
pp 41-56.
bMucosal extension to lingual surface of epiglottis from primary tumors of the base of the tongue and vallecula does not
constitute invasion of larynx.
TNM Staging of H&N CA and Neck Dissection
Classification
Table 2. Regional Lymph Nodes (N)a
NX
Regional lymph nodes cannot be assessed.
N0
No regional lymph node metastasis.
N1
Metastasis in a single ipsilateral lymph node, ≤3 cm in greatest
dimension.
N2
Metastasis in a single ipsilateral lymph node, >3 cm but ≤6 cm in
greatest dimension, or metastasis in multiple ipsilateral lymph
nodes, ≤6 cm in greatest dimension, or in bilateral or
contralateral lymph nodes, ≤6 cm in greatest dimension.
N2a
Metastasis in a single ipsilateral lymph node >3 cm but ≤6 cm in
greatest dimension.
N2b
Metastases in multiple ipsilateral lymph nodes, ≤6 cm in greatest
dimension.
N2c
Metastases in bilateral or contralateral lymph nodes, ≤6 cm in
greatest dimension.
N3
Metastasis in a lymph node >6 cm in greatest dimension.
aAJCC:
Pharynx. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010,
pp 41-56.
TNM Staging of H&N CA and Neck Dissection
Classification
Table 3. Distant Metastasis (M)a
aAJCC:
Pharynx. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer,
2010, pp 41-56.
M0
No distant metastasis.
M1
Distant metastasis.
TNM Staging of H&N CA and Neck Dissection
Classification
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Example Of TNM : T1N1M0 of oral cavity
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T1 - tumor 2cm or less in greatest dimension
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N1 - metastasis in a single ipsilateral lymph node ≤3 cm in greatest dimension
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M0 - no distant metastasis
Staging: World Health Organization
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TNM status of pt tabulated to give numerical status of World Heath Organization
(WHO) Stage I, II, III, IV
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Subdivisions may exist for each stage, may be denoted as a, b, c
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Early-stage disease = Stage I or II, advanced stage disease = Stage III, IV
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Any positive metastatic disease to neck is classified as advanced,
except in select nasopharynx/thyroid cancer
Staging of a H&N Tumors:
Stage
aAJCC:
T
N
M
Pharynx. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 41-56.
0
Tis
N0
M0
I
T1
N0
M0
II
T2
N0
M0
III
T3
N0
M0
T1
IVA
IVB
IVC
M0
T2
N1
M0
T3
N1
M0
T4a
N0
M0
T4a
N1
M0
T1
N2
M0
T2
N2
M0
T3
N2
M0
T4a
N2
M0
T4b
Any N
M0
Any T
N3
M0
Any T
Any N
Background/Problems Treating
Patients with H&N Ca
Background/Problems Treating H&N Ca
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Dysphagia occurs in up to 60% of pts during and post CRT.
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Dysphagia is one of the main predictors of poor post tx quality of life (QOL).
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Outpts w H&N Ca were not receiving a standardized swallow treatment protocol
across all Sharp HealthCare entities.
These problems led to developing one SPP for whole Sharp Healthcare system.
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Question
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This is the question we asked ourselves:
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In the outpatient H&N CA population, is a standardized swallowing preservation
protocol more effective in maintaining per oral intake and QOL outcomes than the
current traditional process of evaluating and treating swallowing dysfunction after
the pt experiences CRT?
Creating A Swallow Preservation Protocol (SPP)
• Where did we start?
Description of Initiative
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Review of the literature
Assessed traditional practice
Retrospective data analysis
Development of SPP
Analysis of SPP pt data
Presented information to sources
Educated SLPs on SPP
Created a competency
Healthcare Professionals Involved:
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Referring MD: primary MD, oncologist, ENT, Otolaryngologist, dentist
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Radiologist: scans tumor (MRI, CT, PET, needle biopsy)
Pt then referred to 1,2, or all of 3 MDs depending on
TNM tumor staging, placement.
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Radiation Oncologist: administers radiation
Chemotherapy Oncologist: administers systemic chemotherapy
Surgeon: excises tumor
Healthcare Professionals Involved:
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Other Related Professionals:
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Dentist: RT= referral for check up- dental work required prior to RT
tooth extraction, deep cleaning, dental trays
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GI Doc: PEG tube placement prior to CRT
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Cancer Patient Navigator: coordinates pt care
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R.D. Board Certified Specialist in Oncology Nutrition:
caloric intake via p.o./PEG tube
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SLP: speech-language/swallow deficits/counseling
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Palliative Care/Hospice Care MD/NSG: for end of life issues
Tumor Rounds/Tumor Board:
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Participate in tumor rounds/board w Radiologists, Radiation/chemotherapy
Oncologists, General Surgeons, Plastic Surgeons, and histopathologists
Also attending: RD, Geneticists, Palliative/Hospice MDs/NSGs, Cancer Patient
Navigator
Role: report on pt’s tx/progress, evals completed (FEES, MBS, strobes)
request consults/referrals for new pts
Head and Neck Ca Screening
Tool
Head and Neck Ca Screening Tool
• No standard/routine screening tests for H&N Ca
• Studies show survival rates reduced secondary to Ca progression when first
diagnosed.
• Early detection = decreased mortality for H&N Ca pts
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Problem:
Most pts diagnosed at advanced stages when < 50% are curable
Therefore, SLP completing screening appears appropriate.
Head and Neck Ca Screening Tool
When to screen: during OME
Teach SLPs to recognize: s/s of H&N CA and refer
• Swelling or sore that does not heal
• Red or white patch in mouth
• Lump/bump/mass in head/neck, w/w-out pain
• Persistent sore throat
• Foul mouth odor not explained by hygiene (halitosis)
• Hoarseness /change in vocal quality
• Nasal obstruction/persistent nasal congestion
• Frequent nose bleeds /unusual discharge
• Difficulty breathing
• Double vision/hearing loss
• Numbness/weakness of a body part in head/neck region
• Odynophagia/difficulty w swallowing/change in diet
• Blood in saliva/phlegm
• Loosening of teeth/ tooth aches
• Dentures that no longer fit
• Unexplained weight loss
• Fatigue
Head and Neck Ca Screening Tool Overview
• www.sixstepscreening.org/dentist-rdh/video-head-neck-exam/
• Detailed video of an intra/extra oral exam/six step screening
• Neck Screening: Palpate neck for tenderness, new lumps on both sides
with fingers.
Head and Neck Ca Screening Tool Overview
• Lips Screening: Palpate upper/lower lip inside and out looking for skin
discoloration/changes, use thumb and index finger.
Head and Neck Ca Screening Tool Overview
• Buccal Cavity Screening: Visually assess cheeks looking in oral cavity for
skin discoloration/changes/sores that have not healed.
• Use fingers feeling for new lumps in both cheeks.
Head and Neck Ca Screening Tool Overview
• Lingual Screening: Visually assess tongue for
discoloration/changes/sores, use finger feeling for new lumps.
• Use 4x4 gauze to hold tongue left and right.
Head and Neck Ca Screening Tool
• Teeth/Gums Screening: Visually assess teeth, gums for
discoloration/changes/sores, use fingers to feel for new lumps on lips and
gums.
Head and Neck Ca Screening Tool
Hard Palate/Velum Screening: Visually assess hard and soft palate for
discoloration/changes/sores. Have pt say “ah”.
Head and Neck Ca Screening Tool
• As SLP use screening only to assess risk - then refer.
• SLPs do not diagnose - only refer.
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Screening results:
Send report/telephone screening results to MD.
Advise pt to follow-up with MD.
SLP follows up with MD.
Head and Neck Ca Screening Tool
Dental hygienists use Toluidine Blue(metachromatic dye) to detect mucosal
abnormalities
• Four chemiluminescence diagnostic aids:
• Vizilite System Plus with Toluidine Blue
• Velscope (visually enhanced lesion) System
• MicroLUX DL System
• Orascoptic DK System
**questionable if theses systems aid in detection and better outcomes.
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Creating Swallow Preservation Protocol
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Changing the culture of referral method is the first step.
Swallow Preservation Protocol (SPP)
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Original Referral Method: Obtain script from rad oncologist when pt shows overt s/s of
dysphagia during/post CRT.
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SPP Referral Method: Obtain script from rad/chemo oncologist prior to CRT.
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Pts to consider for ed./tx: Pt with upcoming RT/CT/CRT or surgery.
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Pre-RT Consult: Pre-RT SPP ed. prevents/lessens negative changes in swallowing.
Pre- Ed. Swallow Preservation
Protocol
Pre- Ed. Swallow Preservation Protocol
A)
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Discuss Possible Structural/Physiological Changes During/Post CRT:
ED. Pt on:
Anatomy/physiology “normal” swallow (use Follow The Swallow)
How RT reduces blood supply to muscle fibers reducing size/strength
Tissue changes of exterior neck, soreness of radiated areas
Risk of bleeding in oral cavity/pharynx
Risk of candida yeast
Risk of dry patchy dermatitis/mucositis/ulcerations
Explain these effects will resolve in 4 to 6 weeks s/p RT
Pre-education Swallow Preservation Protocol
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Ed pt on RT dosages/possible effects:
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Gray (symbol: Gy) is a derived unit of ionizing radiation dose in the International
System of Units (SI). It is defined as the absorption of one joule of radiation energy
per one kilogram of matter.
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Radiation Doses:
T1 tumor:
60-65 Gray dose
T2 tumor:
65-70 Gray dose
T3 tumor
70-75 Gray does
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Daily dose approximately 1.8 Gray per day.
Zerostomia begins approximately at 10-20 Gray.
Zerostomia may become permanent at 40 Gray.
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Meaning zerostomia starts at day 6 w 10.8 Gray and
could be permanent at day 22 w 39.6 Gray.
Trismas significantly increases at 50 Gray to TMJ and/or masseter muscles.
Pre- Ed. Swallow Preservation Protocol
A) Discuss Possible Structural and Physiological Changes During/Post CRT:
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Candida yeast infection on tongue/pharynx/larynx
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Mucositis on tongue, oral cavity, lips
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Dermatitis, ulcerations
Pre- Ed. Swallow Preservation Protocol
A) Discuss Possible Structural and Physiological Changes During/Post RT:
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Possibility of fibrosis of neck tissue during/post RT
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Provide/explain/demonstrate H & N stretching exs.
Head And Neck Stretching Exercises
• Head Forward/Backward:
• This exercise is great for stretching out your neck and getting loose. Stand
or sit with your feet about shoulder width apart and simply nod your head
forward and down as far as possible. From there, rock your head up and
back as far as possible.
Head And Neck Stretching Exercises
• Head Circular Motion:
• This exercise is great for stretching out your neck and getting loose. Stand
or sit with your feet about shoulder width apart and simply roll your head
around in a large circular motion. Do this for 5 repetitions then reverse
directions and repeat in the opposite direction.
Head And Neck Stretching Exercises
• Head Side to Side:
• This exercise is great for stretching out your neck and getting loose. Stand
or sit with your feet about shoulder width apart and simply move your
head from side to side so as to try and touch your left ear to your left
shoulder and your right ear to your right shoulder.
Head And Neck Stretching Exercises
• Head Turn:
• This exercise is great for stretching out your neck and getting loose. Stand
or sit with your feet about shoulder width apart and simply turn your head
from side to side as far as you can each way.
Head And Neck Stretching Exercises
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Isometric Neck Exercises: FRONT and BACK
For the front exercise, place your hands flat on your forehead. Next, firmly push
your forehead forward against your hands. The key to this exercise is to not allow
your forehead to move forward so as to create and maintain constant tension on
your neck muscles. Continue pushing forward for a 10 second count and then
relax. Now switch to the back or rear part of this exercise.
For the rear exercise, begin by clasping your hands behind your head. Next, firmly
push the back of your head against your hands. The key to this exercise is to not
allow your forehead to move backward so as to create and maintain constant
tension on your neck muscles. Continue pushing backwards for a 10 second count
and then relax. Now alternate front and back parts of this exercise.
Head And Neck Stretching Exercises
• Isometric neck exercises: SIDES
Place your right hand flat on the side of your head. Next, firmly push your
head against your right hand. The key to this exercise is not to allow your
head to move so as to create and maintain constant tension on your neck
muscles. Continue pushing against your right hand for a 10 second count and
then switch to the left side and repeat the exercise.
• Taken from: www.shapefit.com
Pre- Ed. Swallow Preservation Protocol
• A) Discuss Possible Structural/Physiological Changes During/Post RT
• Effects of RT on swallowing (difficulty - varied textures/consistencies - rice,
bread, dry foods)
• Taste alterations -enhance taste (e.g. maple syrup, Ca cook books)
• Appetite changes - appetite enhancers (e.g. Megase)
• R.D. consult during/post RT
• Saliva management, odynophagia
• Drying agents - pt unable to manage secretions
• Saliva enhancement products- Xylitol/Biotene
lozenges/gum/drops/sprays/toothpaste
• List of prices/pharmacies
• Do not scare them!
Mouth Moisturizer Products list
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ACT Dry Mouth Lozenges with Xylitol- moderate sized lozenges that you suck.
$5.99 18 pack
Numoisyn Lozenges- small lozenges that you suck
Biotene Oral Balance Liquid- liquid that you spray into oral cavity
$6.69
Biotene Oral Balance Gel- long lasting gel formula you squeeze out into oral cavity
$6.05
Biotene Dry Mouth Oral Rinse- alcohol free liquid that you rinse in your oral cavity
Biotene Dry Mouth Fluoride Toothpaste- brush with this toothpaste for temporary relief
OraCoat XyliMelts- disks to stick to gums or teeth for long lasting relief during day or
especially at night
Rain Spray- oral mist spray
$13.90
Tips To Enhance Eating During Chemotherapy Handout
Cause of Possible Taste Changes During Chemotherapy:
Chemotherapy drugs attack cancer cells which grow rapidly. Taste cells are also cells which grow rapidly. This means
that chemotherapy drugs end up targeting the taste cells along with the cancer cells. When chemotherapy
medications are injected into the bloodstream, they also get into saliva, and most medications have a very bitter
taste, causing a bitter taste in your mouth.
Chemotherapy can also cause foods to not taste the same, for example, foods may often seem too sweet, too salty,
too bitter or without taste at all.
Suggestions to Help Enjoy Foods During Chemotherapy:
Introduce new spices like cumin, cinnamon, and coriander.
If water or food tastes like metal add a little acid such as lemons, limes, or oranges.
If foods taste bitter or harsh add a very small drop of Grade B organic maple syrup.
Add good fats to your cooking, as fat is a natural flavor carrier, such as olive oil,
coconut oil, nuts and seeds.
Holding On To Your Favorite Foods:
Many patients discover that the food eaten during chemotherapy is nearly impossible to consume after treatment
is over due to strong memories and associations of bad tastes of those foods . Therefore, you may want to avoid
eating your favorite foods during chemotherapy so that when treatment is over, you can still enjoy the food you
once loved.
Two Chemotherapy Cook Books:
The Cancer-Fighting Kitchen by Rebecca Katz
One Bite At A Time by Rebecca Katz
Lastly, prior to making any changes with your diet during chemotherapy, please consult your physician and
dietitian.
Pre- Ed. Swallow Preservation Protocol
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Discuss:
Reduce intake of drying agents during/post RT - caffeine-coffee-chocolate-tea
mint-peppermints-menthol
Oral hygiene- brush 3 times daily-reduce bacteria buildup-directly linked to
aspiration PNA
Dental trays throughout RT (SLP reinforces use)
Increasing dental cleanings to 3-4 times per year post RT
(decreased saliva production = damage to dentition over time)
Voice changes (e.g. harsh, hoarse, breathy voice during/post RT) options for tx
Late effects of RT 7-12 years tissue fibrosis, late effects change swallowing
Above structural/functional changes are rare, are only possible effects of RT
Pre- Ed. Swallow Preservation Protocol
B) Aspiration Risk During /Post RT:
Define Aspiration PNA:
• Aspiration pneumonia is often caused by an incompetent swallowing mechanism,
such as occurs in some forms of neurological disease (a common cause being
strokes) or when there is structural or physiological changes post radiation therapy
impeding the swallowing mechanism. Generally the right middle and lower lung
lobes are most common sites of infiltrate formation due to the larger caliber and
more vertical orientation of the right mainstem bronchus. Patients who aspirate
while standing can have bilateral lower lung lobe infiltrates.
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Aspiration pneumonia is typically diagnosed by a combination of clinical
circumstances (debilitated or neurologically impaired patient), radiologic findings
(right lower lobe pneumonia) and microbiologic cultures. Some cases of aspiration
pneumonia are caused by aspiration of food particles or other particulate
substances like pill fragments; these can be diagnosed by pathologists on lung
biopsy specimens.
Pre- Ed. Swallow Preservation Protocol
C) Discuss Pre-Exams:
Define bedside swallow eval/FEES/MBS -reduce test anxiety.
Ed. pt/family what study is/why completing study.
Better understanding = better outcomes
Complete pre-RT FEES for baseline reviewing with pt/family -see tumor for
first time.
• Discuss pre-FEES/mid tx FEES/post tx FEES comparison to ed. with side by
side review.
• Track structural/physiological changes during/post RT.
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Pre- Ed. Swallow Preservation Protocol
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Discuss use of EAT-10 SCALE/FOIS SCALE for pre/post comparison.
Use scales as midterms for encouragement.
Functional Oral Intake Scale
TUBE DEPENDENT (levels 1-3)
1. No oral intake
2. Tube dependent with minimal/inconsistent oral intake
3. Tube supplements with consistent oral intake
TOTAL ORAL INTAKE (levels 4-7)
4. Total oral intake of a single consistency
5. Total oral intake of multiple consistencies requiring special
preparation
6. Total oral intake with no special preparation,
but must avoid specific foods or liquid items
7. Total oral intake with no restrictions
EAT-10 SCALE
LAST NAME, FIRST NAME
SEX
AGE
DATE
0= no problem 1, 2, 3, 4= severe problem
1) My swallowing problem has caused me to lose weight.
2) My swallowing problem interferes with my ability to go out for meals.
3) Swallowing liquids takes extra effort.
4) Swallowing solids takes extra effort.
5) Swallowing pills takes extra effort.
6) Swallowing is painful.
7) The pleasure of eating is affected by my swallowing.
8) When I swallow food sticks in my throat.
9) I cough when I eat.
10) Swallowing is stressful.
Total:
0
0
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
4
4
4
4
4
4
4
4
4
4
A. INSTRUCTIONS:
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Answer each question by writing the number of points in the boxes.
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To what extent do you experience the following problems?
B. SCORING:
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Add up the number of points and write your total score in the boxes.
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Total Score (max. 40 points)
C. WHAT TO DO NEXT: If the EAT-10 score is 3 or higher, you may have problems swallowing efficiently and
safely. We recommend discussing the EAT-10 results with a physician.
Reference: The validity and reliability of EAT-10 has been determined.
Belafsky PC, Mouadeb DA, Rees CJ, Pryor JC, Postma GN, Allen J, Leonard RJ. Validity and Reliability
of the Eating Assessment Tool (EAT-10). Annals of Otology
Rhinology & Laryngology 2008;117(12):919-924.
Pre- Ed. Swallow Preservation Protocol
• Discuss:
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R.D. consult to assess caloric intake during/post RT.
Weekly telephone/e-mail contact
Swallow log during/post RT to self monitor po calorie intake
Vital stim ed.
Assess readiness for PEG tube removal.
Swallow Preservation
Protocol During/Post CRT
Swallow Preservation Protocol During/Post CRT
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Ed. on secretion management strategies - fixed timing for swallows two x per minute
with cough/throat clear/spit into cup/tissue then swallow.
Swallow boot camp, timer to goes off 1x minute to remind pt to swallow.
GERD precautions- sleeping upright at 90 degrees to decrease coughing/aspiration
from secretions.
Bed wedges, raising HOB bed 8-10 inches with books/wood blocks, no eating 90 min
prior to bed.
Mouth moisturizers, humidifiers at night to improve comfort overnight (mouth
breather/Xylimelts).
Strategies will increase sleeping time/aid in recovery secondary to not waking up
every few minutes to clear secretions.
Swallow Preservation Protocol During/Post CRT
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Present pts with list for bed wedges/bed risors:
Elevate HOB 6-8 inches w risors or bed wedge
Swallow Preservation Protocol During/Post CRT
REFLUX SYMPTOM INDEX
Name: _____________________________________ Date: ___/___/___
Within the last month, how did the following problems affect you?
(0-5 rating scale with 0 = No problem and 5 = Severe)
1. Hoarseness or a problem with your voice
012345
2. Clearing your throat
012345
3. Excess throat mucous or postnasal drip
012345
4. Difficulty swallowing food, liquids or pills
012345
5. Coughing after you ate or after lying down
012345
6. Breathing difficulties or choking episodes
012345
7. Troublesome or annoying cough
012345
8. Sensations or something sticking in your throat
012345
9. Heart burn, chest pain, indigestion, or stomach acid coming up
012345
TOTAL: _________
Normative data suggests that a RSI of greater than or equal to 13 is clinically
significant. Therefore a RSI > 13 may be indicative of significant reflux disease.
Swallow Preservation Protocol
Laryngeal Pharyngeal Reflux/Gastro Esophageal Reflux Handout
Definition of Laryngopharyngeal Reflux or LPR:
•
LPR is when stomach acid refluxes into the voice box and throat which may or may not cause the patient heartburn or indigestion.
Symptoms of LPR/GER:
•
Patient may experience coughing, throat clearing, sore throat, voice changes, difficulty swallowing, feeling of food sticking in throat, or
acidic taste in mouth.
Treatment For LPR/GER:
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Treatment may include a pairing of both medication and changes in diet and lifestyle. Severe cases of LPR/GER that are persistent may
require Fundoplication (Nissen Fundoplication) surgery. The procedure essentially tightens the lower esophageal sphincter around the
lower portion of the esophagus to reduce backflow of stomach acids into the esophagus.
Dietary Restrictions:
Food Changes:
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Bland diet
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Reduce high acid content foods such as spicy foods, tomato-based foods.
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Reduce food with mint or menthol.
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Reduce breath mints, throat lozenges.
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Reduce or avoid altogether fatty foods, caffeine, sugary foods, chocolate, onions.
Beverage Changes:
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Reduce caffeine intake.
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Reduce citrus fruits or fruit juice intake.
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Reduce alcohol intake.
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Reduce carbonated drinks such as soft drinks, sodas.
Lifestyle Changes:
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Elevate head of bed four to eight inches with books or blocks or use wedge pillows (do not use soft pillows as it will constrict your
stomach). This will help keep stomach acid from flowing into your esophagus when you are sleeping.
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Avoid eating one to three hours prior to bedtime.
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Stay upright at 90 degrees for 60-90 minutes post meals.
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Avoid overeating.
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Avoid heavy meals that promote large amounts of acid production.
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Avoid or reduce pressure on your stomach, avoid tight constrictive clothing including belts, etc.
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Lose weight if you are overweight. Being overweight puts additional pressure on your stomach and increases the likelihood of LPR/GER
occurring. Even losing a few pounds can help.
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Stop smoking.
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Reduce stress.
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Incorporate an exercise program regularly.
Swallow Preservation Protocol Exercises
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Gargle Exercise: (Aids in base of tongue retraction, swallow timeliness)
Instruction: Gargle with or without water as per instruction and hold gargle for 5-10 seconds.
Number of Repetitions: ______
Number of Times Per Day: ______
Effortful Swallow Exercise: (Aids in posterior contraction for base of tongue, timeliness of swallow)
Instruction: Swallow saliva, ice chips, or liquid as hard as you can. Bear down and swallow hard/fast.
Number of Repetitions: ______
Number of Times Per Day: ______
Mendelson Maneuver: (Aids in hyolaryngeal excursion, coordination of swallow reflex, and cricopharyngeal
opening, strengthens laryngeal muscles to move forward and up.)
Instruction: Place hand on throat and swallow normally to feel laryngeal movement, now swallow again and hold swallow
when larynx is at its highest point for 2-3 seconds before completing swallow.
Number of Repetitions: ______
Number of Times Per Day: ______
Masako Maneuver: (Aids in pharyngeal wall constriction, pharyngeal squeeze)
Instruction: Gently hold tongue in between front teeth and swallow your saliva.
Number of Repetitions:________
Number of Times Per Day: ______
Laryngeal Elevation Exercise: (Aids in elevation of hyolaryngeal muscles, lifts airway out of the way for swallowing)
Instruction: Start with high pitch /ee/ sound and hold for 5 seconds. Second, go from high pitch /ee/ to low pitch /ee/. Third,
go from low pitch /ee/ to high pitch /ee/. Last, produce /ee/ for short bursts for 5 seconds.
Number of Repetitions: ______
Number of Times Per Day: ______
Swallow Preservation Protocol Exercises
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Super Supraglottic Swallow Exercise: (Aids in improved vocal fold adduction and timeliness of pharyngeal swallow,
helps close off airway and improves timing of swallows)
Instruction: Take a breath in, hold breath tightly and bear down, swallow, cough and swallow again with or without water.
•
Number of Repetitions: ______
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Shaker Exercise: (Aids in improved upper esophageal sphincter opening, suprahyoid, infrahyoid, and
sternocleidomastoid muscle movement/strength, helps open esophagus to move food/drink down to stomach)
Instruction: Lie flat (no pillow). Lift your head and look at your toes while keeping your shoulders down and maintain this
position for 60 seconds. Rest for 60 seconds and repeat 3 times. Lift your head up-look at your toes-put your head down in
one smooth motion 30 times.
•
Number of Repetitions: ______
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•
Isometric Neck Exercises: (Aids in improved pharyngeal contraction during swallowing, strengthens swallow
squeeze)
Instruction: This exercise will require a partner. Sit upright at 90 degrees in hard chair. Partner to place left hand on your
chest and right hand on the back of your head with you pushing against your partner’s hand. Then change so partner’s right
hand is on your upper back and your partner’s left hand is on your forehead with you pushing against your partner’s hand.
Your partner will increase pressure as appropriate.
•
Number of Repetitions: ______
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Hyoid Lift Exercise: (Aids in elevation of the hyolaryngeal muscles)
Instruction: This exercise will require you to cut 10 to 20 quarter size pieces of paper and obtain a regular straw. Place
quarter size pieces of paper on surface and you suck approximately ¼ inches above paper circles to lift circles to straw. Hold
circles in place with sucking and place in cup. If increased difficulty is required, cut circles out of cardboard or poster board.
•
Number of Repetitions: ______
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Tongue Press Exercise: (Aids in maintaining tongue strength)
Instruction: Press the tongue surface up into the bony ridge on the roof of mouth
as hard as you can and hold for 5 seconds.
•
Number of Repetitions: ______
•
Number of Times Per Day: ______
Number of Times Per Day: ______
Number of Times Per Day: ______
Number of Times Per Day: ______
Number of Times Per Day: ______
Swallow Preservation Protocol Exercises
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Tongue Protrusion Exercise: (Aids in maintaining tongue range of motion)
Instruction: Stick your tongue out as far as you can past your lower teeth and hold for 5 seconds.
•
Number of Repetitions: ______
•
•
Tongue Retraction Exercise: (Aids in maintaining tongue
strength/range of motion)
Instruction: Pull the back of your tongue to the back of your mouth and hold.
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Number of Repetitions: ______
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Water Swallow Test (WST): (Aids in identifying aspiration and selecting patients who may require
instrumental assessment as CRT progresses.)
Instruction: Swallow 3 ounces of fluid in successive large swallows.
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Number of Repetitions: ______
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Oral-Stretch: (Aids in maintaining mandible/jaw opening)
Instruction: Passively open mouth and hold open mouth for 3 seconds, then stretch mouth opening to the fullest
for 10 seconds.
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Number of Repetitions: ______
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Head & Neck Stretching Exercises: (Aids in maintaining range of motion of neck/swallow muscles and
reduces fibrosis of neck tissue over time.)
Instruction: See separate head and neck stretching exercise instruction sheet
•
Number of Repetitions: ______
Number of Times Per Day: ______
Number of Times Per Day: ______
Number of Times Per Day: ______
Number of Times Per Day: ______
Number of Times Per Day: ______
Swallow Preservation Protocol Exercises
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Trismus Exercise Program
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Yawn and Hold Exercise: (Aids in mandible (jaw) opening, chewing)
Instruction: Yawn normally and hold in open yawn position for 3-5 seconds.
Number of Repetitions: ______
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Mandible (jaw) Stretch Exercise: (Aids in continued maximum opening of jaw, chewing)
Instruction: First allow jaw to slacken without resistance for 3 repetitions. Then open jaw to
maximum and hold for 5-10 seconds with/without pressure and then release.
Number of Repetitions: ______
•
Number of Times Per Day: ______
Number of Times Per Day: ______
Hard Gargle Exercise: (Aids in mandible (jaw) opening, pharyngeal contraction, base of tongue retraction,
swallow timeliness)
Instruction: Gargle with or without water as per instruction and hold gargle for 5 seconds.
Number of Repetitions: ______
Number of Times Per Day: ______
Swallow Preservation Protocol
Weekly Swallow Exercise Log
Date: _______
Exercises completedyes/no
If not completed why: _________________________________________________________________________________________
Comments:___________________________________________________________________________________________________
___________________________________________________________________________________________________________
Date: _______
Exercises completedyes/no
If not completed why: _________________________________________________________________________________________
Comments:___________________________________________________________________________________________________
___________________________________________________________________________________________________________
Date: _______
Exercises completedyes/no
If not completed why: _________________________________________________________________________________________
Comments:___________________________________________________________________________________________________
____________________________________________________________________________________________________________
Date: _______
Exercises completedyes/no
If not completed why: _________________________________________________________________________________________
Comments:___________________________________________________________________________________________________
___________________________________________________________________________________________________________
Date: _______
Exercises completedyes/no
If not completed why: _________________________________________________________________________________________
Comments:___________________________________________________________________________________________________
___________________________________________________________________________________________________________
Date: _______
Exercises completedyes/no
If not completed why: _________________________________________________________________________________________
Comments:___________________________________________________________________________________________________
___________________________________________________________________________________________________________
Date: _______
Exercises completedyes/no
If not completed why: _________________________________________________________________________________________
Comments:___________________________________________________________________________________________________
____________________________________________________________________________________________________________
Pre Ed. Swallow Preservation Protocol
Daily Swallow Log
Date:___________
Solids Consumed:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Liquids Consumed:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
___________________________________________________________________________________
Pain Scale Without Swallowing- (0=no pain 7=severe pain)
0
1
2
3
4
5
6
7
Pain Scale With Swallowing- (0=no pain 7=severe pain)
0
1
2
3
4
5
6
7
For caloric intake to assess readiness for PEG tube removal.
Weekly Weight Chart
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Weekly Weight Chart For PEG Removal:
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Week 1
Date:______
Weight:____
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Week 2
Date:______
Weight:____
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Week 3
Date:______
Weight:____
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Week 4
Date:______
Weight:____
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Week 5
Date:______
Weight:____
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Week 6
Date:______
Weight:____
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Week 7
Date:______
Weight:____
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Week 8
Date:______
Weight:____
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Week 9
Date:______
Weight:____
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Week 10
Date:______
Weight:____
Common Side Effects of CRT
Common Side Effect of Radiation Treatment Sheet
• Fatigue
• Xerostomia (dry mouth)
• Taste changes
• Sore mouth and throat
• Pain and difficulty swallowing
• Skin changes
• Hair loss in treatment area
• Side effects can happen 1-2 weeks after treatment starts and are different for each
patient.
• It is hard to know how long or how severe the side effects may be for you.
• Side effects often get worse during treatment and for 1-2 weeks after radiation
therapy is complete.
• It can take several weeks to months, or longer, for your side effects to improve.
Swallow Preservation Protocol
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Support for People With Oral and Head and Neck Cancer
SPOHNC
Contact Information:
Telephone number- 1-800-377-0928
Web Site- WWW.SPOHNC.ORG
•
The Local chapter of SPOHNC Meets:
4S Ranch Library on first Saturday of the month at 12:30 PM
Address: 10101 Vista Montanoso, Escondido, CA 92026
Contact: Valerie Targia- Telephone number- 1-760-751-2109 or email [email protected]
•
General SPOHNC Information:
SPOHNC has 90 chapters in the United States.
SPOHNC offers eight newsletters a year (free with $25.00 membership fee).
SPOHNC offers National Survivor Volunteer Network (free with $25.00 membership fee):
Survivor Volunteer Network Telephone number- 1-800-377-0928 or [email protected]
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Published Works:
SPONHNC has published:
Self Examination For Head And Neck Pamphlet (free with $25.00 membership fee)
Eat Well-Stay Nourished Cook Book Vol. 1 and Vol. 2 ($40.00 for pair)
We Have Walked In Your Shoes: A Guide To Living With Oral, Head And Neck Cancer
Meeting Challenges Of Oral And Head And Neck Cancer, A Survivor’s Guide ($25.00)
Swallow Preservation Protocol
Swallow For Life Guidelines
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Oral Care:
Brush teeth and tongue at least 3 times daily.
Increase dental cleaning to 3-4 times per year.
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Swallow Precautions:
Follow swallow precautions furnished by your speech language pathologist
(see attached individual swallow precautions sheet).
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Head and Neck Stretching Exercises:
Complete head and neck stretching exercises daily to maintain head and neck ROM (see attached
individual head and neck stretching exercise sheet).
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Swallow Exercises:
Complete specific swallow exercises furnished by your speech language pathologist (see attached
Individual swallow exercise sheet).
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Reflux Precautions:
Follow laryngeal/pharyngeal reflux/gastro esophageal reflux precautions/strategies (see handout
Laryngeal Pharyngeal Reflux/Gastro Esophageal Reflux sheet).
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Pneumonia Shot Yearly:
Obtain a yearly pneumonia vaccine to reduce pneumonia risk.
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Pulmonary Endurance Tasks:
Depending on physical state, increase movement as tolerated and recommended by physician.
Moving/walking post meals will reduce aspiration risk. Do not eat and lay down post meals. Stay
upright for 30 to 90 minutes post meals.
•
Monitor Pulmonary Changes:
Monitor temperatures as appropriate. Low grade fevers, change in vocal quality, increased
coughing/choking during and post meals, increased tearing, runny nose during meals may be overt
signs symptoms of aspiration. If you note any of the above symptoms listed contact your physician
and/or speech language pathologist.
•
Monitor Weight Changes:
Record your weight on a regular basis and inform your physician if you see fluctuation in weight
loss or weight gain (see Weekly Weight Record sheet).
Post Acute Head And Neck Cancer Rehab
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Goal:
Catch pts post tx -slide backwards/monitoring/Q’s/suicidal
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Team Approach:
SLP, Ca pt navigator, R.D., Social Worker
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Format:
Team meets 2x month for 30 min discuss pts.
Pts seen 1x month.
Pts seen individually for 10-15 by each discipline.
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Individual Meeting:
SLP screening- assess pt swallow
Administer EAT-10, FOIS scales
Request script for swallow eval, FEES, swallow tx
as appropriate.
Weekly Oncology Email Updates
Week of 02/22/16 to 02/26/16
• PT STATED MUCH IMPROVED ORAL INTAKE TO 100% VIA PO WITH NO PEG TUBE
FEEDING X 2.5 WEEKS 02/21/16. PT STATED CONT. REDUCED TASTE "PETROLIUM
TASTE" WITH ALL INTAKE. PT COMPLETED CRT 01/25/16. PT IS TOLERATING ALL
TEXTURES AND MAINTAINING WEIGHT AT 165LBS. PT WITH MOD ZEROSTOMIA
AND 3/10 PAIN WITH SWALLOWING. PT/WIFE ED. TRAINED ON SALIVA
ENHANCEMENT PRODUCTS AND USE, INCREASED CHEWING TO IMPROVE SALIVA
VOLUME, ALTERNATING SIPS/BITES TO INCREASE ORAL HYDRATION. PT
COMPLETED LINGUAL EXS. WITH INCREASED ROM/STRENGTH/SPEED. PT
COMPLETED HEAD AND NECK EXS. WITH REDUCED ANTERIOR POSTERIOR AND
RIGHT SIDE ROM. TRISMAS EXS. COMPLETED AND PT/WIFE FURNISHED WITH
WRITTEN EXS. PT WITH 2 FINGERS OPENING. PT WITH CONT. REDUCED SENSATION
ON LOWER RIGHT LIP, CHIN, HOWEVER, PT REPORTED NO DROOLING X 2 WEEKS.
RECOMMEND CONT. LINGUAL, LABIAL, TRISMAS AND HEAD AND NECK EXS., CONT.
REGULAR WITH THIN LIQUIDS AND CONSULT FOR REMOVAL OF PEG TUBE, OT
CONSULT FOR IMPROVING RIGHT SHOULDER, ARM ROM/STRENGH/ENDURANCE.
SPP Post Test Example Questions
What does SPP stand for?
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Swallow Preservation Protocol
Swallowing Per Person
Swallowing Preserved Practicum
The Functional Oral Intake Scale measures?
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Reliability in swallowing
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Amount and consistency of oral intake
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Amount of tube feeding
The EAT-10 measures?
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How many meals eaten in a week
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Pounds of food eaten per meal
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Ounces of liquid intake per meal
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Quality of life
A standardized swallow treatment plan entails?
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Periodic f/u during and throughout CRT/recovery
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Periodic assessments/regimented exercises
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All of the above
Does the swallow preservation protocol reduce?
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Rate of dysphagia
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Aspiration risk/rate secondary to aspiration PNA
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Hospital admissions secondary to dehydration/aspiration PNA
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Time/needed for alternate nutrition (PEG tube)
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All of the above
Internal Study:
The Impact of a SPP on
Pts with H&N Ca
Internal Study:
The Impact of a SPP on Pts with H&N Ca
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Methods:
This project is a pre-post interventional design.
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Patients with H&N CA completed a pre-post functional oral intake scale (FOIS) and
QOL index (EAT-10).
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Oral intake and QOL outcome measures for the SPP group were compared to
traditional swallow therapy group using mixed Analysis of Variance (ANOVA).
Participants
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Three licensed SLPs from Sharp Grossmont Hospital, Sharp Chula Vista Medical
Center, and Sharp Memorial Hospital
16 SPP patients:
• Performed standardized exercises throughout CRT
• Periodic f/u during treatment and through recovery
16 traditional swallow treatment patients:
• Assessed retrospective data analysis from
2012-2014
• Performed non-standardized exercises post onset of dysphagia
Outcomes
Functional Oral Intake Scale (FOIS)
6.1
7
6
5
3.4
4
3.5
2.9
3
2
1
0
Initial SPP
DC SPP
Initial Traditional
DC Traditional
• SPP: FOIS mean scores increased by 3.2, F(1,30)=29.83, p<.0001
• Traditional: FOIS scores increased by only 0.1, F<1
Interpretation:
• SPP: increased from tube supplements with consistent oral intake to total oral
intake with avoiding specific food/liquids only
• Traditional: no significant change
Outcomes Continued
EAT-10 Quality of Life Scale
40
35
30
24.4
22.7
24.7
25
20
15
6.2
10
5
0
Initial SPP
DC SPP
Initial Traditional
DC Traditional
SPP: EAT-10 mean scores decreased by 16.5, F(1,24)=44.91, p<.0001
Traditional: EAT-10 scores increased by 0.3, F<1, lower scores = improved
perceived swallowing function
Interpretation:
• SPP: reported statistically significant perceived improvement in swallowing
comfort/ease and QOL
• Traditional: reported no significant change
•
•
Conclusion
•
•
•
•
SPP made statically significant improvement in swallow function and QOL post
treatment.
SPP increased from tube supplements with consistent oral intake to total oral
intake with avoiding specific food/liquids only.
SPP reported perceived improvement in ease of swallowing and QOL.
Traditional reported no significant change in functional eating and QOL.
Implications
Direct Outcomes:
• Standardization of swallow treatment for patients with H&N Ca across all Sharp
Healthcare entities
• Preservation of swallow function during/post CRT
• Enhanced QOL during/post CRT
• Empowerment for patients in healing process during/post treatment
• Enhanced oncology team
List benefits to MDs
• Less chance of pts requiring alternate feeding (PEG tube) for long periods
of time post CRT.
• Maintain weight - good nutrition throughout CRT via p.o. /PEG
• Pt feels like she is actively participating in own outcome of tx.
• Reduced cost with reduced re-hospitalizations for aspiration
PNA/dehydration.
• Pt feels more informed - outcomes are better- pt happier with overall
experience.
Where Do We Go From Here?
• Continue to forge relationships with MDs to ensure pre CRT/surgery
referrals
• Ed. incoming SLPs/new hires
• Complete yearly competency for all SLPs
• Continue to stay current with H&N Ca literature
• Integrate new literature findings into protocol
• Continue to gather data and monitor strength of SPP with pts
Thoughts? Questions?
References
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Belafsky P, et al, “Validity and Reliability of the Eating Assessment Tool (EAT-10),” Annal of
Otology, Rhinology and Laryngology, 2008, 117 (12): 919-992.
Bhayani M, et al,”Gastrostomy Tube Placement in Patients with Oropharyngeal Carcinoma
Treated with Radiotherapy or Chemotherapy: Factors Affecting Placement and Dependence,”
Head and Neck, 2012, 10: 1634-1640.
Carroll W, et al,”Pretreatment Swallowing Exercises Improve Swallow Function After
Chemoradiation,” Laryngoscope, 2007, 118: 39-43.
Crary M, et al, “Initial Psychometric Assessment of a Functional Oral Intake Scale
for Dysphagia in Stroke Patients,” Archives of Physical Medicine and Rehabilitation, 2005, 86.
Duarte V, et al, “Swallow Preservation Exercises During Chemoradiation Therapy Maintains
Swallow Function,” Journal of the American Medical Association, Otolaryngology Head Neck
Surgery, 2013, 149 (6): 878-884.
Huh Shinn E, et al, “Adherence to Preventitive Exercises and Self-reported Swallowing
Outcomes in Post-radiation Head and Neck Cancer Patients,” Wiley Online Library.com, 2013,
10.1002/hed.23255.
Hutcheson K, et al, “Eat and Exercise During Radiotherapy or Chemoradiotherapy for
Pharyngeal Cancers: “Use It or Lose It”, Journal of the American Medical Association
Otolaryngology Head Neck Surgery, 2013, 139 (11): 1127-1134.
Aurthur G. James Cancer Center Hospital and Richard J. Solove Research Institute March 27th,
2014. The Ohio State University Comprehensive Cancer Center “Common Side Effects of
Radiation Therapy”
References
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•
•
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•
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Kraaijenga S, et al, “Current Assessment and Treatment Strategies of Dysphagia in Head and
Neck Cancer Patients: a Systematic Review of the 2012/2013 Literature,”
www.supportiveandpalliativecare.com, 2014, 8(2): 152-162.
Kramer S, et al, “Prophylactic Versus Reactive PEG Tube Placement in Head and Neck Cancer,”
Otolaryngology-Head and Neck Surgery, 2014, 150(3): 407-412.
Kotz T, et al, “Prophylactic Swallowing Exercises in Patients with Head and Neck Cancer
Undergoing Chemoradiation,” Archives Otolaryngology Head Neck Surgery, 2012, 138(4):376382.
Kulbersh B, et al, “Pretreatment, Preoperative Swallowing Exercises May Improve Dysphagia
Quality of Life,” Laryngoscope, 2006, 116:883-886.
Lazarus H CL, et al, “Effects of Exercise On Swallowing and Tongue Strength In Patients With
Oral and Oropharyngeal Cancer Treated with Primary Radiotherapy with or without
Chemotherapy,” International Journal of Oral and Maxillofacial Surgery, 2014, 43:523-530.
Logemann J, et al,”Site of Disease and Treatment Protocol as Correlates of Swallowing
Function in Patients with Head and Neck Cancer Treated with Chemoradiation,” Head Neck,
2006, 28(1): 64-73.
Paleri V, et al, “Strategies to Reduce Long-Term Postchemoradiation Dysphagia in Patients
with Head and Neck Cancer: An Evidence-based Review,” Wiley Online Library, 2013,
10.1002/hed.2351.
Patterson J, Wilson J, “The Clinical Value of Dysphagia Preassessment in the Management of
Head and Neck Cancer Patients,” Current Opinion in Otolaryngology and Head and Neck
Surgery, 2011, 19:177’181.
References
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•
“Screening For Oral Cancer Using Light-Based Techniques: A review of the Diagnostic
Accuracy, Cost Efficiveness, and Guidelines.” Canadian Agency For Drugs and Technologies in
Health, September 10, 2013.
Wang M,“Swallowing Exercises Help to Preserve Function After RT and CRT,”
www.onclive.com/publications/Oncology-live/2013/November-2013/swallowing-exerciseshelp-to-preserve-function-after-rt-and-crt#sthash.8SltHxjw.dpuf, 2013.