2019 feb - dysphagia hnc (vanderbilt) handout€¦ · dysphagia in hnc (hutcheson, vanderbilt...
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Dysphagia in Head and Neck CancerOptimizing outcomes through standard pathways and evaluation protocols
Kate A. Hutcheson, PhDAssociate Professor
Department of Head and Neck Surgery
MD Anderson
Disclosures
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
• PCORI 1609-36195
• NCI R01CA218148
• NCI R03CA188162
• NCI R01CA214825
• NCI R21CA226200
• NIDCR R01DE025248
• MD Anderson Institutional Research Grant Program
• MD Anderson Survivorship Seed Monies Research Grant Program
• NCI CTEP NCORP Seed Monies Grant Program
• Charles & Daneen Stiefel MD Anderson Oropharynx Program Fund (PRO/Function Core)
• American Board Swallowing & Swallowing Disorders: non-financial
MD Anderson
Dysphagia is common in HNC
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
Two‐year prevalence of dysphagia and related outcomes in head and neck cancer survivors: An updated SEER‐Medicare analysis
(n=16,194, 2002 - 2011)
Hutcheson KA, Lewis, CM, et al. Head Neck (e-pub 2019)
multimodality
single modality
sx
RT
CRT
SRT
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Impact of dysphagia
Health QOL
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Quality of life
r = 0.49 – 0.56, p<0.001(n = 72 OPC U Michigan swallowing-optimized IMRT trial)
Largest effect size of all toxicities (larger than xerostomia)
Hunter KU, Eisbruch A, et al. Int J Radiat Oncol Biol Phys (2013)
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Dysphagia is top symptom associated with decisional regret
Recursive partition with bootstrap re-sampling MDASI-HN symptoms by Decisional regret, (n=972, median 6Y disease-free survival time)
Goepfert, RP, Hutcheson KA, et al. Head Neck (e-pub 2017)
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Aspiration pneumonia
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
SEER-Medicare2000-2009, n=3,513
chemoradiation for HNC
23.8% (5Y)
Xu B, Murphy JD, et al. Cancer (2014)
MD Anderson
Aspiration as source of late non-cancer deaths
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n=116, 56% OPC, mean 33 mos FU
Szczesniak, MM, Cook, IJ, et al. Clin Oncol (2014)
MD Anderson
Dysphagia in HNC is complex….
Tumor• Site• Size
Patient• Age• Comorbidities• Psycosocial• Support• Function
Surgery• Approach• Site/size• Reconstruction
Radiation• Dose• Fields • Fractionation • Technique
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Distinct subsites
TNM staging
Different treatment modalities
Head & Neck CancerHead and neck cancer
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What is the “Head & Neck”?
H&N
• “Upper aerodigestive tract”• Borders of the H&N:
• Superiorly: skull base• Inferiorly: trachea• Anteriorly: nose• Posteriorly: pharyngeal
wall
NOT H&N
• Esophagus• Cervical spine• Lungs• Trachea• Brain
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Anatomic regions of H&N
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Visualization of H&N Regions
a
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Endoscopy Fluoroscopy
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Key functions of the H&N region
Respiration
SwallowingSpeech
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H&N structures: What are the functional correlates?
Larynx (voicebox)• supraglottis• glottis• subglottis
Oral Cavity (mouth)• oral tongue• floor of mouth• gums• mandible/maxilla• retromolar trigone• buccal / lip
Oropharynx (throat)• soft palate• tonsil• base of tongue• post pharyngeal wall
Hypopharynx (throat)• piriform sinuses• postcricoid region• post pharyngeal wall
Nasopharynx (throat)
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Review of CN functions
V• Sensory: hard/soft palate (V2), anterior tongue (V3)• Motor (V3): suprahyoid (anterior excursion), palate (VP closure), masticatory muscles
VII• Sensory: anterior tongue (taste)• Motor: labial, facial, posterior digastric (laryngeal elevation)
IX• Sensory: posterior tongue, faucial arches, oropharynx• Motor: stylopharyngeus
X• Sensory: SLN BOT, hypopharynx, supraglottis, glottis; RLN subglottis• Motor: pharynx, palate, intrinsic larynx, cricopharyngeus
XII• Motor: intrinsic & extrinsic tongue, hyolaryngeal excursion
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12th most common malignancy (U.S.)
49,260 new cases 2010
11,000 deaths/year
Prevalence ~350K
>90% SCCA
Survival: 5-year ~60%
Head and neck cancer
Jemal A et al. CA Cancer J Clin (2010)
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
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Shifting epidemiology of HNC
↑ frequency of non-surgical organ preservationNCI SEER (2011)
Cooper JS, et al. Head Neck (2009)
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HPV epidemic: impact on HNC incidence
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HPV associated disease is different
Vidal & Gillison (2009)Chaturvedi AK, et al. JCO (2011)
Ang KK, et al. NEJM (2010)
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Primary site
http://www.nccn.org/professionals/physician_gls/pdf/head-and-neck.pdf
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Regional
http://www.nccn.org/professionals/physician_gls/pdf/head-and-neck.pdf
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TNM Classification
T
(tumor)
Tumor size or extent of involvement
Varies some by site of primary tumor
TX: Primary tumor cannot be assessed
T0: No evidence of primary tumor
T1*: varies by site
T2*: varies by site
T3*: varies by site
T4*: varies by site, invades adjacent structures
*varies by site
N
(nodal status)Important predictor of survival
NX: Regional lymph nodes cannot be assessed
N0: No regional lymph nodes
N1*: Single ipsilateral node, ≤ 3 cm
N2a-c*: Single ipsilateral node 3-6 cm, or multiple nodes < 6 cm
N3*: >6cm (single or multiple)
Varies by site
M
(metastases) Rare at presentation (typically lung)
MX: Distant metastases cannot be assessed
M0: No distant metastases
M1: Distant metastases
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
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AJCC Staging(non-NPC, non-OPC)
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AJCC Staging, 8th edition (update)Oropharynx cancer
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
p16 (HPV) positive p16 (HPV) negative
Lydiatt, Patel, O’Sullivan, et al. Ca Cancer J Clin. (2017)
MD Anderson
Evolution of HNC treatment
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
1940 1950 1960 1970 1980 1990 2000Before1900
Surgery
Radiation Therapy
Chemotherapy
Biological Therapy (targeted therapy)
Courtesy of Dr. F. Christopher Holsinger
2010
Immunotherapy
MD Anderson
Single modality
Combined modality
Single versus Multi-modality
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Treatment options for oral cancers
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
• surgeryDefinitive
• Induction chemotherapy (preop)
• Postoperative radiation (± chemo)
Adjuvant
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Treatment options for oropharyngeal cancers
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
• radical surgeryHistorically
• Organ preservation (radiation/chemoradiation)1990’s
• Transoral surgery2000’s
• De-intensified RT (low-intermediate risk)
• Immunotherapy• Transoral surgery
2010’s
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Treatment options for oropharyngeal cancers
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
Current
Low-intermediate risk (HPV+) and
low T stage
Transoral surgery
RT +/- systemic
HPV- and advanced T stage
Chemoradiation(~70 Gy)
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Treatment options for early laryngeal cancer
Single modality therapy
RT alone (narrow field)
SurgeryTLMS (laser)
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
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Treatment options for advanced laryngeal cancer
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
Multi-modality therapy
Laryngeal preservation ChemoRT (US standard)
Partial laryngectomy + PORT
Total laryngectomy+
PORT
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Treatment options for hypopharyngeal cancers
• RT ± chemo• eHNS – laser or robot
Early stage “larynx
preservation”
• Total laryngopharyngectomy• Postoperative RT ± chemo
Advanced stage
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Sources of dysphagia in HNC
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
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Dysphagia in HNC is complex….
Tumor• Site• Size
Patient• Age• Comorbiditi
es• Psycosocial• Support• Function
Surgery• Approach• Site/size• Reconstruction
Radiation• Dose• Fields • Fractionation • Technique
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
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Patient factors
Age• Sarcopenia • Frailty
Comorbidity Functional reserve
Psychosocial factors motivation, ability, adherence
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Tumor-associated dysphagia
Primary site Lymph nodes
http://www.nccn.org/professionals/physician_gls/pdf/head-and-neck.pdf
T-stage
Site Volume Approach Closure Neck
Post‐surgical dysphagia
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know what to look for
Managing postsurgical dysphagia
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Surgical factors to consider
Surgical considerations Details that impact swallowing outcome
Location of resection • Normal function of structure(s)• Size defect (t-stage)• Adjacent structures
Approach • Open approach (transcervical, mandibulotomy)• Minimally invasive/transoral/endoscopic approaches
•Transoral laser microsurgery (TLM)• Transoral robotic surgery (TORS)
Closure • Healing by secondary intention• Primary closure (local suture)• Reconstruction:
• Regional flap• Free flap (plastic surgeon)
Neck dissection • Extent of ND• Levels (I-V)• Selective vs. radical
• Laterality (unilateral/bilateral)
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
Partial glossectomy = RANGE OF MOTION
partial glossectomies + flaps: less ROM
partial glossectomies + 1° closure: betterROM
Healing by 2°intention: best ROM
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
(sub)Total glossectomy = bulk
Day of surgery 5 mos. postop
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Protuberant
Semi-protuberant
Flat
Concave
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
Copyright © 2015 American Medical Association. All rights reserved.
From: Risk Factors Predicting Aspiration After Free Flap Reconstruction of Oral Cavity and Oropharyngeal Defects
Arch Otolaryngol Head Neck Surg. 2008;134(11):1205-1208. doi:10.1001/archotol.134.11.1205
Post-swallow aspiration residue Post-RT inefficiency BOT as “pump” (McConnel et al. Lscope 1988)
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
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Partial laryngectomy
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
post-cordectomy
post-vertical partial
post-supraglotticpost-supracricoid
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Postop swallowing rehabilitation – a practical hierarchy
1. Saliva management
2. Re-introduce PO (safest, most efficient)MBS: rule out leak/assess safety (advanced-stage)
3. Increase volume of POmass practice
4. Increase complexity of PO
Hutcheson, KA, Lewin JS, In: HNC: Evidence-Based Treatment, Argiris, Ferris, & Rosenthal (2018)
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expect (and address) post-surgical edema
Postsurgical dysphagia
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
LymphedemaFunctional impact?
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H&N Lymphedema Therapy ProgramIntensive Phase + home program
COMPLETE DECONGESTIVE TX1. Manual lymphatic drainage2. Compression therapy 3. Remedial exercise 4. Skin care
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
n=733
60% CDT responders
Adherence (p<0.001)
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Radiation-Associated Dysphagia “RAD”Safety Efficiency
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“Organ preservation”Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
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VA Laryngeal Cancer Study
68%68%64%
0
25
50
75
100
Larynx preservation Estimated 2-year survival
Pe
rce
nt
PF induction → RT (n=166)
Surgery + RT (n=166)
The Department of Veterans Affairs Laryngeal Cancer Study Group. N Engl J Med. 1991;324:1685.
Median follow-up = 2 years Median follow-up = 33 months
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Laryngeal Preservation: RTOG 91-11%
P
R E
S E
R V
E D
0
25
50
75
100
YEARS FROM RANDOMIZATION0 1 2 3 4 5
ConcurrentInduction RT alone
88%
75%
69%
Induction vs Concurrent p= 0.0048Induction vs RT alone p= 0.27Concurrent vs RT alone p= 0.00012
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51 studies
6,400 pooled patients
Compared 2 approaches:
• Surgery + PORT
• RT +/- chemotherapy
Equivalent survival and LRC
Complications in surgical group
Organ Preservation: OropharynxDefinitive surgery v. RT?
Parsons et al. Cancer (2002)
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The standard of care for organ preservation?
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
Chemoradiation
66-72 Gy
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Organ preservation ≠ functional preservation
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Radiation injury/toxicities
King SN, Pitts, T, et al. Dysphagia (2017)
Early
• Acute (<3M)• Subacute (3-6M)• Mucosal• Cell death• Inflammation
Late
• >3-6M• Deeper tissue• Vascular• Connective tissue• Salivary/oral
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Toxicity GradingCommon Toxicity Criteria for Adverse Events (CTCAE)
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Patterns of Acute Toxiticies:MD Anderson Symptom Inventory (MDASI-HN)
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
Gunn GB et al. Cancer (2014)
Patient‐reported symptoms during RT
MD Anderson
MBS PRO
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
Pharyngeal constrictor
dose>50 Gy
Laryngeal dose
>20-30 Gy
MD Anderson
Dale, Hutcheson, Fuller, et al MD Anderson Symptom Working Group. Head Neck (2016)
Floor of mouth (suprahyoid) muscle dose predicts RAD in OPC survivors (n=349)
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Older patients tolerate less radiation dose to swallowing muscles before developing dysphagia
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
- Age: 70 – 79 - Age: 60 – 69 - Age: 50 – 59- Age: 40 – 49
Abbreviations: NTCP, normal tissue complication probability; ROIs, regions of interest; ADM, anterior digastric muscle; GGM, genioglossus muscle; IPC, inferior pharyngeal constrictor; ITM, intrinsic tongue muscle; MGM, mylo/geniohyoid muscles; MPC, middle pharyngeal constrictor; PDM, posterior digastric muscle; SPC, superior pharyngeal constrictors
Christopherson, Hutcheson, Fuller, et al MD Anderson Symptom Working Group. Unpublished (2019)
MD Anderson
Acute
(edema)
Chronic
(fibrosis)
Late
(denervation)
Dysphagia-Aspiration Related Structures (DARS): ↓ mobility
Eisbruch et al, IJROBP (2004)Hutcheson et al, Cancer (2012)
Early/ chronic
RAD
LateRAD
Pathophysiology RAD
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
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RAD
MechanicsLaryngeal closure
Bolus push
Esophageal opening
Structure Edema
Defect
Stricture
Aspiration
Residue
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Dysphagia is not always stricture after RT
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
Wang, Goldsmith, et al. Head Neck (2012)
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Collaborative management: the esophagus
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
Rosenthal DI, Lewin JS, Eisbruch A. Prevention and treatment of dysphagia and aspiration after chemoradiation for head and neck cancer. J Clin Oncol 24(17):2636-2643, 6/2006.
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Gastroenterology (GI) or ENT/HNS
EGD w/ esophageal dilation:
• Bougie (“push”)
• Balloon dilation
• Rendevouz
Management of stricture
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Esophageal dilation improves symptomatic stricture
- n = 41 HNC survivors
- ≥12M post RT NED
- Sham controlled RCT (EGD +/- dilation)
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
Wu, P, Szczesniak M., Maclean J, et al. Disease Esophagus (2018)
75%76% 5%
Note: short term response rate in redStricture relapse rate = 50%
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When to suspect stricture
“Spit cup”
Can’t belch or vomit
High risk site + prolonged NPO
Solid-food dysphagia (sometimes)
Stricture: common symptoms
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When to suspect stricture
Large volume liquid
AP (high density barium)
Oblique?
Pharyngeal function
Hyolaryngeal kinematics (frozen larynx?)
Stricture: evaluating on fluoro
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T2N1 SCCA Supraglottis 6M post chemoRTSternal recurrence 4M post re-RT
Pre-dilation Post-dilation
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Lymphedema-Fibrosis continuum
n = 100 HNC with RTPre-RT to 18M post-RT
75% moderate-severe lymphedema47% grade ≥2 fibrosis
lymphedema external
lymphedema internal
fibrosis
Ridener SH, Murphy B, et al. Lymph Res Biol (2016)
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Lower cranial neuropathy (LCNP) as rare late effect of RT – 5% incidenceIX, X, XII nerves, median latency 8 years (n=59 IMRT OPC survivors)
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
Hutcheson KA, et al. Head Neck (2017)
overall survival87% at 10 years
incidence LCNP5% (median FU 6 years)
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Denervation source?
Chemotoxicity
Compressive (peripheral
axonal)
Brainstem nuclei
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
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LCNP associated significantly worse cancer-related symptoms largest impact on swallow and voice/speech
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
n = 889 OPC survivors
Median 7 year survival time
4% incidence of LCNP
MD Anderson Symptom Inventory-Head and Neck Module (MDASI-HN) survey responses
Aggarwal P, et al. JAMA-Oto HNS (2018)
mucusswallowing
voice/speech
Late Dysphagia
“Late‐RAD”
Significant inefficiency
Refractory aspiration
Progressive dysfunction
Secondary pneumonia
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Late‐RAD
1 year 7 yearsPre‐RT
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Acute
(edema)
Chronic
(fibrosis)
Late
(denervation)
Dysphagia-Aspiration Related Structures (DARS): ↓ mobility
Eisbruch et al, IJROBP (2004)Hutcheson et al, Cancer (2012)
LateRAD
Denervation (cranial neuropathy) common in late-RAD
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
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LCNP associated with late functional decline
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
Hutcheson KA, et al. Head Neck (e-pub 2017)
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MBS PRO
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
Pharyngeal constrictor
dose>50 Gy
Laryngeal dose
>20-30 Gy
MD Anderson
Dose-response varies over time
Christianen MEMC, Verdonck-de-Leeuw I, Langendijk JA, et al Radiotherapy Oncolog (2015)
Grade ≥2 Dysphagia (EORTC)
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
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n=38, (12 cases, 26 controls)
ROI:SPC, IPC,MPC
CP angleMedulla
Peripheral nerve tractFOMBOT
ParotidsLarynx
Palate (hard/soft)Retropharyngeal space
Intrinsic tongue
MVA adjusted for T-stage, total RT dose
Late RADCases: 70.5 Gy vs. Controls: 61.6 Gy
Lower cranial neuropathyCases: 71.1 Gy vs. Controls: 61.8 Gy
Awan MJ, Fuller CD, Hutcheson KA, et al, Oral Oncol(2014)
SPC mean dose
SPC mean dose
LCNPno LCNP
late-RADno late-RAD
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Evolution of RAD
Acute“transient”
Chronic or persistent Late-onset
Edema Edema-fibrosis Fibrosis-neuropathy
High dose larynx High RT dose larynx, pharynx
Moderate dose upper pharynx
Goldsmith T & Jacobson M, Curr Opin Otolaryngol Head Neck Surg (2018)
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Evaluating dysphagia in HNC
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
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What’s the pathophysiology?
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
Difficulty swallowing
SOLIDS
Poor propulsion (pharyngeal)
Stricture
Prep:
Mastication or saliva
Difficulty swallowing
LIQUIDS
Poor laryngeal (supraglottic)
closure
Residue
(propulsion v. stricture)
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MDACC Swallowing Evaluation Protocol
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
MBS• Efficiency• Penetration-aspiration• Pathophysiology
Patient-reported outcomes (PROs)• MDADI
Functional status scale• PSS-HN (Diet,
Eating in Public)
pre post
MD Anderson
Performance Status Scale – Head & Neck Cancer (PSS-HN)
Understand-ability of
Speech
• 100= Always understandable• 75= Usually understandable (occasional repetition)• 50= Sometimes understandable (face-to-face)• 25= Difficult to understand• 0= Never understandable
Normalcy of Diet
• 100= Full diet (no restriction)• 90= Full diet (liquid assist)• 80= All meat• 70= Raw vegetables• 60= Dry toast, cracker• 50= Soft, chewable• 40= Soft, nonchewable• 30= Pureed• 20= Liquid (warm)• 10= Liquid (cool)• 0= NPO
Eating in Public
• 100= No restriction (people, place, food)• 75= Restrict food in public• 50 = Certain people, certain places• 25 = At home, certain people• 0 = Always eats alone
• Clinician-rated
• Semi-structured interview
• 3-items
• NCCN recommended
• Best = 100, Worst = 0
• Don’t average the score
List M, et al. Cancer (1990)
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
MD Anderson
MD Anderson Dysphagia Inventory
Chen, A. et al. Arch Oto-HNS. (2001)
• 20-item PRO
• Scores:
• Best = 100
• Worst = 20
• 3 subscales:• Emotional
• Functional
• Physical
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
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Quantifying MBS?
Function•Safety
•Efficiency
Pathophysiology•Kinematics
•Timing
Penetration/Aspiration Residue DIGEST
Leonard‐Kendall Logemann
Martin‐Harris (MBSImP) Pearson
Steele (ASPEKT)Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP
Course | 2019)
MD Anderson
Dynamic Imaging Grade of Swallowing Toxicity (DIGEST)
MBS tool: pharyngeal dysphagia severity (global)
5-point severity staging, CTCAE benchmarksgrade 0=none, 1=mild, 2=moderate, 3=severe, 4=life threatening/profound
Safety (Pen-Asp) x Efficiency (residue) interaction
For therapy profiling!
S3 E0 DIGEST3 versus S1 E3 DIGEST 3
Hutcheson KA, et al. (2017) Cancer
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
S0 S1 S2 S3 S4
E0
0 1 2 3 3
E1
1 1 2 3 3
E2
1 2 2 3 3
E3
2 2 3 3 4
E4
3 3 3 4 4
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
2/19/2019
32
S0 S1 S2 S3 S4
E0
0 1 2 3 3
E1
1 1 2 3 3
E2
1 2 2 3 3
E3
2 2 3 3 4
E4
3 3 3 4 4
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
MD Anderson
Dynamic Imaging Grade of Swallowing Toxicity (DIGEST)
MBS tool: pharyngeal dysphagia severity (global)
5-point severity staging, CTCAE benchmarks0=none, 1=mild, 2=moderate, 3=severe, 4=life threatening/profound
Safety (Pen-Asp) x Efficiency (residue) interaction
For therapy profiling! (ex: S1 E4 D3)
Hutcheson KA, et al. (2017) Cancer
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
DIGEST Grade 0
MD Anderson
Dynamic Imaging Grade of Swallowing Toxicity (DIGEST)
MBS tool: pharyngeal dysphagia severity (global)
5-point severity staging, CTCAE benchmarks0=none, 1=mild, 2=moderate, 3=severe, 4=life threatening/profound
Safety (Pen-Asp) x Efficiency (residue) interaction
For therapy profiling! (ex: S1 E4 D3)
Hutcheson KA, et al. (2017) Cancer
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
DIGEST Grade 0
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MD Anderson
Dynamic Imaging Grade of Swallowing Toxicity (DIGEST)
MBS tool: pharyngeal dysphagia severity (global)
5-point severity staging, CTCAE benchmarks0=none, 1=mild, 2=moderate, 3=severe, 4=life threatening/profound
Safety (Pen-Asp) x Efficiency (residue) interaction
For therapy profiling! (ex: S1 E4 D3)
Hutcheson KA, et al. (2017) Cancer
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
DIGEST Grade 1
MD Anderson
Dynamic Imaging Grade of Swallowing Toxicity (DIGEST)
MBS tool: pharyngeal dysphagia severity (global)
5-point severity staging, CTCAE benchmarks0=none, 1=mild, 2=moderate, 3=severe, 4=life threatening/profound
Safety (Pen-Asp) x Efficiency (residue) interaction
For therapy profiling! (ex: S1 E4 D3)
Hutcheson KA, et al. (2017) Cancer
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
DIGEST Grade 2
MD Anderson
Dynamic Imaging Grade of Swallowing Toxicity (DIGEST)
MBS tool: pharyngeal dysphagia severity (global)
5-point severity staging, CTCAE benchmarks0=none, 1=mild, 2=moderate, 3=severe, 4=life threatening/profound
Safety (Pen-Asp) x Efficiency (residue) interaction
For therapy profiling! (ex: S1 E4 D3)
Hutcheson KA, et al. (2017) Cancer
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
DIGEST Grade 3
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MD Anderson
Dynamic Imaging Grade of Swallowing Toxicity (DIGEST)
MBS tool: pharyngeal dysphagia severity (global)
5-point severity staging, CTCAE benchmarks0=none, 1=mild, 2=moderate, 3=severe, 4=life threatening/profound
Safety (Pen-Asp) x Efficiency (residue) interaction
For therapy profiling! (ex: S1 E4 D3)
Hutcheson KA, et al. (2017) Cancer
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
DIGEST Grade 4
MD Anderson
Other measures to consider: Oral Intake
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
Steele C, et al. Arch PMR (2018)
Level Description
Tube dependent
1 NPO
2 Tube dependent with minimal attempts of food or liquid
3 Tube dependent with consistent oral intake of food or liquid
Fully oral
4 Total oral diet of single consistency
5 Total oral diet of multiple consistencies, but requiring special preparations or compensations
6 Total oral diet with multiple consistencies without special preparation, but with specific food limitations
7 Total oral diet with no restrictions
Functional Oral Intake Scale (FOIS) IDDSI-Functional Diet Scale (IDDSI-FDS)
Crary M et al Arch PMR(1995)
MD Anderson
EAT-10
Sydney Swallow Questionnaire (SSQ)
SWAL-QOL
Other swallowing questionnaire options
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
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35
MD Anderson
Tongue strength (MILS)
Mouth opening (MIO)
Cough (PCF)
Laryngoscopy
Adjunctive functional measures
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
MD Anderson
Mucositis, odynophagia,
mucus↓ oral intake Disuse
atrophy?
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
MD Anderson
Eat
Exercise
Use it or lose
it!
Preventive swallowing therapy
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
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36
MD Anderson
Evidence for Proactive Swallowing Therapy: ExerciseStudy Outcomes
UAB Retrospective Superior MDADI (swallow-related QOL)1
Better BOT & epiglottic movement2
MDACC Retrospective Shorter duration PEG (OPC & HP)3
Adherence improves MDADI (swallow-related QOL)4
UF RCT Significant preservation muscle mass by MRI5
NKI RCT Improved mouth opening6
Mt Sinai RCT Superior diet levels (3-6M after CRT)7
Japan Retrospective Less aspiration8
Less PEG dependenceLess hospitalization
1. Kulbersh BD et al, Lscope (2006), 2. Carrol WR et al, Lscope (2008)3. Bhayani M et al, Head Neck (2013)4. Shinn E et al, Head Neck (2013)5. Carnaby-Mann G et al, IJROBP (2012)6. Van der Molen L et al, Dysphagia (2011)7. Kotz T et al, Arch Oto-HNS (2012)8. Ohba S et al, Head Neck (2014)
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
Cochrane review (Perry, 2016) inconclusiveMeta-Analysis (Grecco, Martino, 2018) benefit
MD Anderson
Evidence for Proactive Swallowing Therapy: Eat
Gillespie B et al, Lscope (2004)
Part PO
NPO
End RT diet
MDADIscores ̅ 4.7± 3.4 yrs
100% PO
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
Langmore S et al, Dysphagia (2012)
MD Anderson
Use it or lose it:Eat and Exercise during Radiation (n=497, pharyngeal cancers 2002-2008)
Adherent58%
Non-adherent
42%
Fully PO40%
Partially PO34%
NPO26%
Eat
Exercise
Hutcheson, Bhayani, Beadle, Gold, Shinn Lai, Lewin. JAMA‐OtoHNS (2013)
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
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MD Anderson
Use it or lose it study: EAT and Exercise are feasible during RT
MDACC retrospective review: Eat & Exercise during radiation (n=497, pharyngeal cancers 2002-2008)
Adherent58%
Non-adherent
42%Fully PO
40%
Partially PO
34%
NPO26%
EatExercise
Hutcheson, Bhayani, Beadle, Gold, Shinn Lai, Lewin. JAMA‐OtoHNS (2013)
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
MD Anderson
Use it or lose it study: EAT and Exercise associated with greater chance of returning to regular diet long-termMDACC retrospective review: Eat & Exercise during radiation (n=497, pharyngeal cancers 2002-2008)
Hutcheson, Bhayani, Beadle, Gold, Shinn Lai, Lewin. JAMA‐OtoHNS (2013)
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
MD Anderson
Use it or lose it: EAT and Exercise associated with shorter feeding tube dependenceMDACC retrospective review: Eat & Exercise during radiation (n=497, pharyngeal cancers 2002-2008)
Hutcheson, Bhayani, Beadle, Gold, Shinn Lai, Lewin. JAMA‐OtoHNS (2013)
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
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38
mid-RT 6-8 weeks post end-
RT
3-6 monthspost end-RT
18-24 monthspost end-RT
5 yearspost end RT
PRE end-RT
Clinic Counsel exercise
Clinic H2O screen exercise
Clinic H2O screen exercise
Clinic CSE exercise
Clinic MBS FU
MDADI
MBS
MD Anderson Radiation Swallowing Pathway
MDADI
MBS
MDADI
MBS
MDADI
MBS
H&N cancer patients with cancers of oral cavity, larynx*, pharynx (OPC, NPC, or HP), or UPC dispositioned to receive bilateral neck RT ± chemo
*note: T1‐2 N0 TVF receiving narrow field excluded (unless age>80)
PSS-HN PSS-HN PSS-HN PSS-HN PSS-HN PSS-HN PSS-HN
Clinic MBS FU
Clinic MBS FU
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
Source: MD Anderson Cancer Center, Section Speech Pathology & Audiology
MD Anderson
Pathways work!
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
Dance Head and Neck PathwayGreater Baltimore Medical Center
Messing B, et al. Dysphagia (2018)
mid-RT 6-8 weeks post end-
RT
3-6 monthspost end-RT
18-24 monthspost end-RT
5 yearspost end RT
PRE end-RT
Clinic Counsel exercise
Clinic H2O screen exercise
Clinic H2O screen exercise
Clinic CSE exercise
Clinic MBS FU
MDADI
MBS
MD Anderson Radiation Swallowing Pathway
MDADI
MBS
MDADI
MBS
MDADI
MBS
H&N cancer patients with cancers of oral cavity, larynx*, pharynx (OPC, NPC, or HP), or UPC dispositioned to receive bilateral neck RT ± chemo
*note: T1‐2 N0 TVF receiving narrow field excluded (unless age>80)
PSS-HN PSS-HN PSS-HN PSS-HN PSS-HN PSS-HN PSS-HN
Clinic MBS FU
Clinic MBS FU
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
you are here
Source: MD Anderson Cancer Center, Section Speech Pathology & Audiology
2/19/2019
39
mid-RT 6-8 weeks post end-
RT
PRE end-RT
Clinic Counsel exercise
Clinic H2O screen exercise
Clinic H2O screen exercise
Clinic CSE exercise
MDADI
MBS
MD Anderson OPC and Radiation Swallowing Pathway
H&N cancer patients with cancers of oral cavity, larynx*, pharynx (OPC, NPC, or HP), or UPC dispositioned to receive bilateral neck RT ± chemo
*note: T1‐2 N0 TVF receiving narrow field excluded (unless age>80)
PSS-HN PSS-HN PSS-HN PSS-HN
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
MD Anderson
Proactive exercise training
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
Mendelsohn Jaw/FOM stretch Supraglottic Masako Effortful
3 sets, 10 reps
Source: International Radiation Associated Dysphagia Working Group
MD Anderson
EAT – Eat All Through Radiation
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
EAT diet staircase (food hierarchy)
Mealtime routine
Source: International Radiation Associated Dysphagia Working Group
2/19/2019
40
mid-RT 6-8 weeks post end-
RT
3-6 monthspost end-RT
18-24 monthspost end-RT
5 yearspost end RT
PRE end-RT
Clinic Counsel exercise
Clinic H2O screen exercise
Clinic H2O screen exercise
Clinic CSE exercise
Clinic MBS FU
MDADI
MBS
MD Anderson Radiation Swallowing Pathway
MDADI
MBS
MDADI
MBS
MDADI
MBS
H&N cancer patients with cancers of oral cavity, larynx*, pharynx (OPC, NPC, or HP), or UPC dispositioned to receive bilateral neck RT ± chemo
*note: T1‐2 N0 TVF receiving narrow field excluded (unless age>80)
PSS-HN PSS-HN PSS-HN PSS-HN PSS-HN PSS-HN PSS-HN
Clinic MBS FU
Clinic MBS FU
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
Source: MD Anderson Cancer Center, Section Speech Pathology & Audiology
post RT
mid-RT 6-8 weeks post end-
RT
3-6 monthspost end-RT
18-24 monthspost end-RT
5 yearspost end RT
PRE end-RT
Clinic Counsel exercise
Clinic H2O screen exercise
Clinic H2O screen exercise
Clinic CSE exercise
Clinic MBS FU
MDADI
MBS
MD Anderson Radiation Swallowing Pathway
MDADI
MBS
MDADI
MBS
MDADI
MBS
H&N cancer patients with cancers of oral cavity, larynx*, pharynx (OPC, NPC, or HP), or UPC dispositioned to receive bilateral neck RT ± chemo
*note: T1‐2 N0 TVF receiving narrow field excluded (unless age>80)
PSS-HN PSS-HN PSS-HN PSS-HN PSS-HN PSS-HN PSS-HN
Clinic MBS FU
Clinic MBS FU
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
Source: MD Anderson Cancer Center, Section Speech Pathology & Audiology
If functional swallow:
“maintenance” education
MD Anderson
Maintenance exercise & education
Tips for Eating“You may feel solid foods stick abnormally in your throat while you eat. Although you may want to grab a drink to wash the food through the throat, try a hard, fast swallow instead to help clear the food. You may need to repeat this several times. It is good exercise for your throat when you swallow thick or heavy foods”
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
2/19/2019
41
mid-RT 6-8 weeks post end-
RT
3-6 monthspost end-RT
18-24 monthspost end-RT
5 yearspost end RT
PRE end-RT
Clinic Counsel exercise
Clinic H2O screen exercise
Clinic H2O screen exercise
Clinic CSE exercise
Clinic MBS FU
MDADI
MBS
MD Anderson OPC and Radiation Swallowing Pathway
MDADI
MBS
MDADI
MBS
MDADI
MBS
H&N cancer patients with cancers of oral cavity, larynx*, pharynx (OPC, NPC, or HP), or UPC dispositioned to receive bilateral neck RT ± chemo
*note: T1‐2 N0 TVF receiving narrow field excluded (unless age>80)
PSS-HN PSS-HN PSS-HN PSS-HN PSS-HN PSS-HN PSS-HN
Clinic MBS FU
Clinic MBS FU
Biofeedback
If DIGEST ≥2:
Boot camp Device-
facilitated exercise
Biofeedback
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
MD Anderson
Dysphagia Therapies
1980’s 1990’s 2000’s
Compensations
ExercisesBiofeedback Electrical
stimulation
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
Electrical stimulation for RAD?
R01 funded multi‐site RCT:• “Chronic” RAD (≥3 months post RT or CRT)• 2 arms:
– Swallow exercise & stretching + NMES– Swallow exercise & stretching + sham NMES
• 3 month intensive home program– BID, 6 days/week
Primary aim: NS effect NMES
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Efficacy of popular therapies for RAD
“home program therapies”
Persistent RAD is DIFFICULT to fix!
Secondary analyses NMES trial
• Efficacy home exercise:– Significant (small) gains diet, QOL
– NS effects MBS detected OPSE, PAS, hyoid excursion
• Time-dependent effects:
– >10 yrs post• Worst pre-therapy swallows
• Progressive deterioration despite therapy
– Threshold @ 2 years?
Langmore, Kriscuinas, et al. DRS (2015)
Limitations of home program
Static program (lack progression)
Rely solely on patient adherence
Low intensity
More structured and progressive swallowing therapy programs needed!
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
MD Anderson
stimulate biofeedback
electrical stimulationBiofeedback assisted skill
trainingTongue press
“e-stim”“NMES”
“Vital Stim”“AmpCare”
resistance
“IOPI”“iPRO – Swallow Strong”
“RST”“bioFEESback”
“HRM”“sEMG”
strength skill
Expiratory training
“”EMST”
More intensive options for persistent/chronic/late dysphagia
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
stretch
mobility
ROM exerciseManual therapy
Myofascial release
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MD Anderson
Skill/strength training“Boot Camp”
McNeil
EFFICIENCY
Skill training
“RST”
Resp Pattern
SAFETY
Strength training
“EMST”
Exp M. Strength
SAFETY
Manual“MFR”
Myofascial release
MOBILITY
More intensive swallowing therapies for persistent/chronic/late dysphagia
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
MD Anderson Swallowing BOOT CAMP
Progressive resistive functional exercise program
sEMG Biofeedback“device-driven”
MDTP“bolus- driven”
“Mass practice”
Intensive, daily
QD or BID
2-3 weeks
FUNCTIONAL task = swallowing
Intensifies over time = progressive, resistive swallowing (exercise) paradigm
Home carry-over (min 6-8 wks)
MD Anderson
MDACC Boot Camp Experience
sEMG and/or MDTP (n=29)
Global Composite Emotional Physical Functional20
40
60
80
Me
an M
DA
DI
sco
res
Pre
PrePrePre
Pre
PostPost
PostPost Post
{p=.05 {
{
{
{p=.12
p=.08
p=.21
p=.22
Pre-Post MDADI Scores. Mean MDADI scores pre-post boot camp swallow therapy. Global MDADI significantly improved (Δ+11.1, p=0.049)
Pre-Post Pen-Asp Scores. Penetration aspiration scale scores pre-post boot camp (Δ0, p=0.999)
QOL improves(efficiency)(adaptation)
Aspiration persists
Hutcheson, Kelly, Barrow, Barringer, Perez, Little, Weber, Lewin. COSM 2014
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
2/19/2019
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MD Anderson
Airway protection
Downstream targets respiratory system?
Respiratory pattern training (Martin-Harris, 2014)
Expiratory muscle strength training - EMST (Sapienza, 2009)
Keep eating
Avoid pneumonia
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
MD Anderson
Therapeutic target = airway protection
Adjustable spring-loaded expiratory valve
CLEARANCE: expiratory force
AIRWAY CLOSURE: hyolaryngeal lift
PUMP: velopharynx
Expiratory Muscle Strength Training (EMST)
Hutcheson K, et al. Laryngoscope. (2017)
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)swallows
EMST exercise
MD Anderson
Expiratory Muscle Strength Training (EMST)
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
Hutcheson K, et al. Laryngoscope (2017)
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MD Anderson
Maximum expiratory pressures significantly improve after EMST in post-RT HNC aspiratorspre-post 8 weeks of EMST (5-5-5, 75% individualized MEP, n=23)
57%↑, p<0.001
Hutcheson K, et al. Laryngoscope (2018)
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
MD Anderson
MBS resultsDIGEST safety profiles significantly improve after 8 weeks EMST (n=23)
Hutcheson K, et al. Laryngoscope. (2018)
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
Less frequent or better cleared aspiration post-EMST
“no longer running to bathroom to regurgitate my food at restaurants”
“cough is stronger”
“less mucus in my throat”
“I bought the trainer for friends in my support group”
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
2/19/2019
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MD Anderson
Integration of Manual Therapy into Speech and Swallow Rehabilitation Program for Head and Neck Cancer: A Case Series (n=15)
15 HNC survivors; 59 combined MT sessions
RT ±surgery or chemotherapy
Primary endpoint: cervical range of motion (CROM)
Secondary outcomes: functional status interview
Lewin JS, Woodall HE, Porsche CB, Barrow MP, Hutcheson KA (2017, MDACC unpublished)
SexFemaleMale
2 (13%)13 (87%)
Age, median (range) 67 (53-79)
Survival time, median mos. (range)
98 (2-192)
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
MD Anderson
All 15 improved CROM
CROM significantly improved >10º on avg after one session
80% pts improved 4 planes, 60% in 5 planes
Lewin JS, Woodall HE, Porsche CB, Barrow MP, Hutcheson KA (2017, MDACC unpublished)
CROM significantly improved after single session
“lift your head as high as you can”
CROM extension
-2°
CROM extension
-50°
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
MD Anderson
Myofascial release
Massage
Passive and Active ROM
Manual Therapy for Fibrosis-Related Late Effect Dysphagia in Head and Neck Cancer Survivors: The Pilot MANTLE trial (2018-0052, NCI R21CA226200)
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
HNC survivor >2Y post-RT with late-
RAD
CROMMBSMRIPROs
Pre-MT
Wk 1 Wk 2 Wk 3 Wk 4 Wk 5 Wk 6
CROMMBSMRIPROs
Post-MTmanual therapy
6 weeks home
practice
washout
CROMMRIPROs
Post-washout
“lift your head as high as you can”
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MD Anderson
EVALUATION CONSENSUS
Therapy phase 1:
Optimize pre-boot camp
Therapy Phase II:
“Boot Camp”
MD Anderson’s work flow for implementing “Boot Camp”
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
MD Anderson
Good therapy starts with comprehensive evaluationMDACC Swallowing Evaluation Standard
MBS• Efficiency• Penetration-aspiration• Pathophysiology
Patient-reported outcomes (PROs)• MDADI
Functional status scale• PSS-HN (Diet,
Eating in Public)
pre post
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
MD Anderson
DIGEST
Hutcheson KA, et al. (2017) Cancer
MBS tool (pharyngeal dysphagia)
5-point severity staging
CTCAE benchmarks0=none, 1=mild, 2=moderate, 3=severe, 4=life threatening/profound
Safety (Pen-Asp) x Efficiency (residue) interaction
FOR BOOT CAMP profiling! (ex: S1 E4 D3)
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MD Anderson Evaluation…
Other data you need to plan boot camp
Treatment history – time post treatment
Disease status
Pneumonia history
Cranial nerve examination
Trismus
Wound issues/pain control (radionecrosis, ulcers, mucositis)
Prior therapy (and response)
Goal (priority!)
MD Anderson
Checklist for swallowing boot camp planning
Evaluation results:MBS date: __ / __ / __DIGEST grade: __ overall __safety __efficiencyMBS pathophysiology:PSS-HN diet:Tube status:MIO:Cranial nerve function:
Optimization phase: Dilation Botox VC medialization Therabite/jaw ROMManual therapy IOPI/lingual strengthening EMST Dental rehab (specify:_____)
Functional therapy phase (boot camp): McNeil Dysphagia Therapy Program (start level:
______) sEMG biofeedback swallows bioFEESback
History: Age: Comorbidity: HNC details: Pneumonia history: Prior swallowing therapy: Patient’s goal:
Candidacy: Cancer free Free active tissue issue (mucositis, ulcer, untreated ORN) Minimal/no oropharyngeal pain
History & evaluation Therapy plan
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
MD Anderson
Checklist for swallowing boot camp planning
Evaluation results:MBS date: __ / __ / __DIGEST grade: __ overall __safety __efficiencyMBS pathophysiology:PSS-HN diet:Tube status:MIO:Cranial nerve function:
Optimization phase: Dilation Botox VC medialization Therabite/jaw ROMManual therapy IOPI/lingual strengthening EMST Dental rehab (specify:_____)
Functional therapy phase (boot camp): McNeil Dysphagia Therapy Program (start level:
______) sEMG biofeedback swallows bioFEESback
History: Age: Comorbidity: HNC details: Pneumonia history: Prior swallowing therapy: Patient’s goal:
Candidacy: Cancer free Free active tissue issue (mucositis, ulcer, untreated ORN) Minimal/no oropharyngeal pain
History & evaluation Therapy plan
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
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49
MD Anderson
Checklist for swallowing boot camp planning
Evaluation results:MBS date: __ / __ / __DIGEST grade: __ overall __safety __efficiencyMBS pathophysiology:PSS-HN diet:Tube status:MIO:Cranial nerve function:
Optimization phase: Dilation Botox VC medialization Therabite/jaw ROMManual therapy IOPI/lingual strengthening EMST Dental rehab (specify:_____)
Functional therapy phase (boot camp): McNeil Dysphagia Therapy Program (start level:
______) sEMG biofeedback swallows bioFEESback
History: Age: Comorbidity: HNC details: Pneumonia history: Prior swallowing therapy: Patient’s goal:
Candidacy: Cancer free Free active tissue issue (mucositis, ulcer, untreated ORN) Minimal/no oropharyngeal pain
History & evaluation Therapy plan
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
MD Anderson
Optimization Phase
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
Dilation Botox VC medialization Therabite/jaw ROMManual therapy IOPI/lingual strengthening EMST Dental rehab (specify:_____)
MD Anderson
Checklist for swallowing boot camp planning
Evaluation results:MBS date: __ / __ / __DIGEST grade: __ overall __safety __efficiencyMBS pathophysiology:PSS-HN diet:Tube status:MIO:Cranial nerve function:
Optimization phase: Dilation Botox VC medialization Therabite/jaw ROMManual therapy IOPI/lingual strengthening EMST Dental rehab (specify:_____)
Functional therapy phase (boot camp): McNeil Dysphagia Therapy Program (start level:
______) sEMG biofeedback swallows bioFEESback
History: Age: Comorbidity: HNC details: Pneumonia history: Prior swallowing therapy: Patient’s goal:
Candidacy: Cancer free Free active tissue issue (mucositis, ulcer, untreated ORN) Minimal/no oropharyngeal pain
History & evaluation Therapy plan
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
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MD Anderson Swallowing BOOT CAMP
Progressive resistive functional exercise program
sEMG Biofeedback“device-driven”
MDTP“bolus- driven”
“Mass practice”
Intensive, daily
QD or BID
2-3 weeks
FUNCTIONAL task = swallowing
Intensifies over time = progressive, resistive swallowing (exercise) paradigm
Home carry-over (min 6-8 wks)
MD Anderson
Biofeedback driven BOOT CAMPsurface electromyography (sEMG)
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
Reading amplitude of muscle activity (through skin)
Not stimulating contractions
Work at % of max, increase over time
With or without bolus
MD Anderson
Swallow “form”
Volume
Viscosity
Bolus-Driven Boot Camp
McNeill Dysphagia Therapy Program (MDTP)
Mass practice
Food hierarchy
Strengthening & coordination
Carnaby-Mann & Crary. Arch PMR (2008)
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
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MD Anderson
Device-driven(sEMG
biofeedback)
Bolus-driven
(McNeill“MDTP”)
Tube removal 27% 67%
Dysphagia recovery (per FOIS) 12% 75%
Continued aspiration
62% 35%
Comparing functional therapy options for boot camp
N=24
Chronic dysphagia (>6M)
75% HNC
Short-term outcomes assessment (end therapy)
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
T2 N2 NPC
9 year survivorFlight attendant
↓
chemoIMRT(70 Gy/33 fx, cis 100mg/m2)
↓
Maintaining weightModerate dysphagia (DIGEST 2)
S0 E3 D2↓
Mild dysarthriaTongue “fatigue”
No pneumonia
MDADI = 55
PSSHN = 50
CN examhemitongue paresis, atrophy, fasciculation
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
Post‐boot camp (MDTP)5‐months later
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
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MD Anderson
To my hero,
You make a difference! I came here 3 weeks ago with a life that was all but over. Yes, the cancer was gone but the inability to swallow/eat left me with a very shallow, empty life. All that is now changed. You didn’t give me a silver bullet, but rather you gave me the courage to try to take baby steps, to believe in miracles, the impossible. No, eating is not the same, but it is manageable. Thank you so much for your training, wisdom, knowledge, dedication, kindness, compassion, but most importantly your passion for serving and helping to heal others. You are a good woman! I pray nothing but the best for you in the future.
You make a difference!
Reflections on boot camp for late-RAD
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
MD Anderson
https://www.cancer.org/health-care-professionals/american-cancer-society-survivorship-guidelines/head-neck-cancer-survivorship-care-guidelines.html
Xerostomia
Caries
ORN
Carotid stenosis
Hypothyroidism
Musculoskeletal
Dysphagia
Stricture
Pneumonia
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
MD Anderson
Interdisciplinary considerations
Veteran’s Affairs Interdisciplinary Clinical Demonstration Project:
SLP therapy (device assisted tongue strengthening exercise)
Pulmonary monitoring (ID nurse practioner)
Nutrition monitoring (RD)
↓ hospital admission (56%, 7.3 mean bed days, $2.1M)
↓ pneumonia diagnoses (67%, 0.43 HR)
Rogus-Pulia N, Robbins J, et al. JAGS (2017)
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MD Anderson
Doing more for oral care?
A meta-analysis could only be done on 4 trials; this analysis showed a significant risk reduction
in pneumonia through oral care interventions(RRfixed, 0.61; 95% CI, 0.40-0.91; P=.02).
Kaneoka A, Pisegna J, Miloro K, Lo M, Saito H, Riquelme L, Langmore S. Inf Control Hosp Epi (2017)
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
MD Anderson
What about late-RAD?
Late-RAD responds poorly to “traditional” rehab?Traditional rehab = home program exercise ± dilation
Hutcheson KA, et al. Cancer (2014)
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
MD Anderson
Late-RAD: aspiration pneumonia
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
Hutcheson KA, et al. Cancer (2012)
86%
aspiration pneumonia rate in late-RAD cases (25/29 cases)
52% hospitalized 14% intubated/trach
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MD Anderson
“I cannot fix this”
Evaluation:• Videofluoroscopy MUST (>90% silent aspirators)• Cranial nerve exam prefer endoscopy• Manometry
Management:• Avoid pneumonia• Avoid NPO • Strategies, strategies, strategies biofeedback (FEES)• Myofascial release• “Home exercise” = not enough
Late-RAD
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)
MD Anderson What else?
…elective TL
MD Anderson
100% resumed PO
74% regular or soft
70% TEP among whom, 88% successful
Considerations:
• Pre-TL function: CN exam, stricture, trismus
• Extent TL: flap?
Yes, you eliminate aspiration, but how do they function?
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MD Anderson
• Dysphagia in HNC is common and complex
• Not all HNC impacts swallowing function similarly
• Standardized evaluation protocol and pathways offer a framework to optimize care
• Be pro-active use it or lose it
• Consider intensive, multi-disciplinary paradigms for persistent/chronic or late onset dysphagia
Conclusions
Dysphagia in HNC (Hutcheson, Vanderbilt Medical SLP Course | 2019)