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Dysphagia and Dysphonia following Organ Preservation for Head & Neck Cancer Treatment. ASHA Convention Boston, 2007 Donna Tippett, Heather Starmer, Kim Webster Johns Hopkins University Department of Otolaryngology, Head & Neck Surgery. Outline. Introduction to organ preservation

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dysphagia and dysphonia following organ preservation for head neck cancer treatment

Dysphagia and Dysphonia following Organ Preservation for Head & Neck Cancer Treatment

ASHA Convention

Boston, 2007

Donna Tippett, Heather Starmer, Kim Webster

Johns Hopkins University

Department of Otolaryngology, Head & Neck Surgery

outline
Outline
  • Introduction to organ preservation
  • Oral motor exercises and dysphagia
  • Related toxicities
    • Trismus
    • Xerostomia
  • Dysphonia
  • Quality of Life
  • Summary, questions & answers
learner objectives
Learner objectives
  • Demonstrate understanding of functional impact of organ preservation approaches on swallowing and voice
  • Discuss the impact of toxicities on swallowing and voice
  • Describe therapeutic interventions that may be beneficial
  • Discuss current literature influencing clinical decision making
terminology
Terminology
  • Organ preservation
  • Organ conservation
  • Primary radiotherapy
  • Chemoradiation
  • Induction chemotherapy
  • Adjuvant chemo-/radiotherapy
  • Neoadjuvant
  • Combined modality
  • Clinical trials and protocols
functional outcomes and h n cancer
Functional Outcomes and H&N Cancer
  • Treatment modality
  • Locus of tumor
  • Other factors
patient factors
Age

Gender

Culture

Family support

Previous swallowing problems

Motivation

Geographic location

Other health history

Occupation

Complications

Prioritizing

Quality of life

Patient Factors
slide7

Sticking

Pain

No appetite

Trismus

Nausea

Vomitting

Dry throat

Fear

Mucositis

No taste or smell

Choking

Dry mouth

Swelling

Fistula

No energy

Fatigue

Stitches

other considerations
Tracheostomy tubes:

Can reduce laryngeal elevation

Irritation of airway

Can reduce laryngeal sensation

Occlude for swallow

Window

Feeding tubes:

Reduce anxiety

Allows for learning

Greater energy

Maximize nutrition

Other Considerations
predicting dysphagia from tx radiation therapy may cause
Mucositis

Xerostomia

Edema

Trismus

Dental caries

Candida

Altered smell and taste

Reduced appetite

Fibrosis

Osteoradionecrosis

Odynophagia

Predicting Dysphagia from TxRADIATION THERAPY may cause:
swallowing post xrt
Swallowing post XRT

Oropharyngeal Symptoms

  • Reduced soft palate elevation
  • Reduced swallow initiation
  • Reduced BOT retraction
  • Thickened immobile epiglottis
  • Reduced laryngeal elevation
  • Reduced airway protection
  • Reduced pharyngeal contraction
  • Reduced cricopharyngeal opening
  • Stricture(s)
  • Webs
predicting dysphagia from tx
Predicting Dysphagia from Tx

Chemotherapy/Organ Preservation:

  • Nausea
  • Oral mucositis
  • Fatigue
  • Other side effects from radiation ’d
  • Longer recovery from effects

Preservation of organ ≠ preserved function

predicting dysphonia from tx radiation therapy may cause
Fibrosis

Xerostomia

Edema

Mucositis

Atrophy

Decreased pliability of the vocal folds

Reduced glottic closure

Impaired vibration of the mucosal surface

Reduced amplitude of vibratory excursion

Supraglottic compensation

Predicting Dysphonia from TxRADIATION THERAPY may cause:
voice post xrt
Voice post XRT

Voice symptoms:

  • Reduced pitch variability
  • Reduced loudness
  • Reduced phrase length
  • Hoarse or breathy vocal quality
  • Vocal strain
  • Vocal fatigue
  • Reduced ability to sing
dysphagia treatment at jh
Dysphagia Treatment at JH
  • Before organ preservation therapy
    • Educate
    • Exercise
    • Evaluate
  • During
    • Make behavioral accommodations, modifications
    • Review exercises, should be done daily if possible
    • Monitor/Evaluate
  • After
    • Evaluate; changes occur up to 15 years later
    • Continue home exercises for a minimum of 4-6 weeks after tx
    • Initiate formal dysphagia tx as indicated
dysphonia treatment at jh
Dysphonia Treatment at JH
  • Before organ preservation therapy
    • Educate
    • Exercise
    • Evaluate
  • During
    • Make behavioral accommodations, modifications
    • Review exercises, should be done daily if possible
    • Monitor/Evaluate
  • After
    • Evaluate as needed
    • Continue prophylactic exercises for at least 4-6 weeks after tx
    • Implement formal intervention if necessary
pre treatment information
Pre-treatment Information
  • Reduces anxiety
  • Improves post-treatment compliance
  • Involves the patient as a team member
  • Better post-tx speech targets
  • Assess writing, legibility, socio- and occupational communication needs

Lazarus, 2005; Glaze, L. 2005

medical surgical tx for dysphagia dysphonia
Medical/Surgical Tx for Dysphagia/Dysphonia
  • Vocal fold medialization by injection
  • Dilatation
  • Surgery
    • Cricopharyngeal myotomy/Botox
    • Soft tissue augmentation (tongue base)
    • Oral prosthetics
    • Supraglottic/glottic closure
    • Medialization thyroplasy
    • Laryngotracheal separation (LTS)
    • Total laryngectomy
    • Rerouting salivary ducts
    • Dennervation of salivary glands
organ preservation approaches and dysphagia
Organ Preservation Approachesand Dysphagia
  • Nature of dysphagia after organ preservation tx
  • Recovery of swallowing function
  • Swallowing intervention
characteristics of dysphagia
Characteristics of Dysphagia
  • Goguen et al, 2006
    • Prospective cohort study
    • N = 23 s/p CRT for head/neck SCCA
    • Common deficits
      • Decreased epiglottic tilt
      • Decreased BOT retraction
      • Decreased laryngeal elevation
      • Impaired bolus propulsion
      • Laryngeal penetration/aspiration
      • 14/23 pharyngoesophageal narrowing
characteristics of dysphagia21
Characteristics of Dysphagia
  • Dworkin et al, Dysphagia, 2006
    • Retrospective study
    • Performed FEES in individuals with Stage III/IV laryngeal SCCA
    • Multiple decompensations
      • Excess oropharyngeal secretions
      • Premature spillage into vallecula
      • Retention in vallecula
      • Post cricoid residue
      • Laryngeal penetration/aspiration
characteristics of dysphagia22
Characteristics of Dysphagia
  • Logemann et al, Head Neck, 2006
    • Examined differences in swallowing across tumor sites and CRT protocols
    • VFSS pre- and 3 months post tx
    • N = 53 with Stage III/IV head/neck SCCA
    • Common deficits
      • Reduced BOT retraction
      • Reduced tongue strength
      • Delayed laryngeal vestibule closure
characteristics of dysphagia23
Characteristics of Dysphagia
  • Pauloski et al, Head & Neck, 2006
    • Prospective cohort study
    • VFSS pre- and post tx
    • N = 170 with head/neck SCCA
    • Identified multiple decompensations
    • Limitations in oral intake and diet post tx were significantly related to:
      • Reduced laryngeal elevation
      • Reduced CP opening
      • Rating of nonfunctional swallow on at least 1 bolus type
recovery
Recovery
  • Goguen et al, Otolaryngol Head Neck Surg, 2006
    • Prospective cohort study
    • F/u at 3, 6, 9, 12, 24 months post tx
    • N = 59
    • Primary tumor sites: oral cavity, oropharynx, hypopharynx, larynx
recovery25
Recovery
  • Goguen et al, 2006
recovery26
Recovery
  • Dworkin et al, Dysphagia, 2006
    • N = 14 with Stage III/IV laryngeal SCCA
    • <12 months: 43% regular/near normal diet
    • >12 months: 86% regular/near normal diet
recovery27
Recovery
  • Pauloski et al, 2006
dysphagia therapy29
Dysphagia Therapy
  • Targets
    • BOT retraction
    • Tongue strength
    • Laryngeal elevation

Goguen et al, 2006

Logemann et al, 2006

Pauloski et al, 2006

slide30
EBP
  • Internal source of information
    • Best clinical judgment
    • Knowledge of anatomy/physiology
  • External source of information
    • Electronic database search
    • PubMed Clinical Queries

Coyle J & Leslie P, Perspectives on Swallowing

and Swallowing Disorders, 2006

exercise principles
Exercise Principles
  • Goal selection
  • Specificity of training
  • Overload/progression

Clark H, AJSLP, 2003

exercise principles32
Exercise Principles
  • Goal selection
  • Specificity of training
  • Overload/progression

Clark H, AJSLP , 2003

exercise principles33
Exercise Principles
  • Goal selection
  • Specificity of training
  • Overload/progression

Clark H, AJSLP , 2003

theoretically sound exercise
Theoretically Sound Exercise
  • Mendelsohn maneuver
    • Addresses goals for:
        • Stretching: maintaining maximum laryngeal elevation over several seconds
        • Strengthening: sustaining laryngeal elevation against resistance
    • Meets criteria for specificity and progression

Clark H, AJSLP , 2003

theoretically sound
Theoretically Sound?
  • Tongue resistance exercise
    • Involves an isometric, static contraction
    • Address strengthening
    • May meet the criteria for progression
    • Does not meet criteria for specificity
swallowing maneuvers
Swallowing Maneuvers

Supraglottic, super-supraglottic, tongue-hold, effortful swallow, and Mendelsohn

Increased laryngeal elevation and laryngeal vestibule closure with maneuvers

Improved airway protection

Tongue base-pharyngeal wall pressures and contact duration increased with maneuvers

Lazarus et al, Head Neck,1994

Logemann et al, Head Neck, 1997

Lazarus et al, Folia Phoniatri Logopaed, 2002

theoretically sound37
Theoretically Sound?
  • Voluntary swallow maneuvers
    • May address strengthening and/or stretching
    • May meet the criterion for progression
    • Meet the criterion for specificity
swallowing intervention
Swallowing Intervention
  • Kulbersh et al, Laryngoscope, 2006
    • Cross sectional analysis of QOL to determine efficacy of pre-tx intervention
    • Administered MDADI
    • N = 25 pre tx swallowing exercises
    • N = 12 post tx swallowing exercises
swallowing intervention39
Swallowing Intervention
  • Kulbersh et al, 2006
    • Adjusted Mean Scores on MDADI
efficacious approach
Efficacious Approach
  • Need to determine what you are targeting
  • Specify the rationale for tx
  • Match the exercise as closely as possible to the desired outcome
  • Try exercises at baseline
  • Document changes in fx, QOL, weight
trismus
Trismus
  • Dijkstra et al , Oral Oncol, 2004
    • Prevalence 5% - 38% in head/neck cancer
    • Variation secondary to lack of uniform criteria, visual assessment, retrospective review
criteria for trismus
Criteria for Trismus
  • Normal MIO 46+7mm

Steelman et al, Mo Dent J, 1986

  • MIO < 30 – 35mm

Buchbinder et al, J Oral Maxillofac Surg, 1993; Dijkstra et al, J Oral Maxillofac Surg, 2006

treatment for trismus
Treatment for Trismus
  • Buchbinder et al, J Oral Maxillofac Surg, 1993
    • N = 21 s/p resection of oral SCCA and radiation tx <5 years
treatment for trismus45
Treatment for Trismus
  • Cohen et al, Arch Phys Med Rehab, 2005
    • N = 7 s/p surgery for oropharyngeal SCCA

p < .01

treatment for trismus46
Treatment for Trismus
  • Dijkstra et al, Oral Oncology, 2007
    • Retrospective study
    • N = 27 patients with trismus secondary to head/neck SCCA and 8 with trismus secondary to other dx
    • Treatment included
      • Active ROM
      • Hold relax techniques
      • Manual stretching
      • Joint distraction
      • Use of devices and tools
treatment for trismus47
Treatment for Trismus
  • Dijkstra et al, 2007

p < .05

oral health
Oral Health
  • Xerostomia
  • Relationship between oral hygiene and aspiration
  • Oral cancer self-examination
xerostomia visual inspection of the mouth
XerostomiaVisual Inspection of the Mouth
  • Tongue depressor sticks to buccal mucosa
  • “Lipstick” sign
  • Dry, sticky or erythematous oral mucosa
  • Red patches on palate, tongue
  • Decreased lingual papillae
  • Little pooled saliva in FOM
  • Stringy, ropy, foamy saliva
when residual gland function remains
When residual glandfunction remains…
  • Can recommend:
    • Fresh, light acidic fruits
    • Slices of cold cucumber, tomato, melon, apple
    • Sour tasting, sugarless candy
    • Chewing gum
    • Vitamin C tablets per MD approval
  • Encourage routine and professional dental care
when saliva production cannot be stimulated
When saliva productioncannot be stimulated…
  • Can recommend
    • Frequent sips of water
    • Saline mouth rinse
    • Oral lubricants
    • Glycerin (may irritate oral mucosa)
    • Room humidifier
      • Criswell et al, Laryngoscope, 2001: Vapotherm MT-3000
when saliva production cannot be stimulated53
When saliva productioncannot be stimulated…
  • Can recommend changes in diet to avoid damage to fragile mucosa
    • Avoid dry, spicy foods
    • Avoid temperature extremes
    • Avoid alcohol, tobacco, caffeine, sugar containing products
  • Encourage routine and professional dental care
when saliva production cannot be stimulated54
When saliva productioncannot be stimulated…

Momm et al, Strahlentherapie und Onkologie, 2005

  • Crossover study comparing four saliva substitutes
  • Best treatment was very individual
  • Recommend that patients try different agents to identify what works best for them
when saliva production cannot be stimulated55
When saliva productioncannot be stimulated…
  • Biotene and Oralbalance
    • Contain salivary enzymes to suppress microbial colonization, inflammation
    • Decreased oral dryness (Regelink et al, Quintessence Int, 1998; Warde et al, Support Care Cancer, 2000)
    • No antimicrobial action; limited dwell time (Epstein et al, Oral Oncology,1999)
oral hygiene
Oral Hygiene
  • “Ignore your teeth and they’ll go away.”
oral hygiene57
Oral Hygiene
  • Terpenning et al, J Am Geriatr Soc, 2001
    • But potential respiratory tract pathogens will still colonize in saliva, and on oral mucosa and denture surfaces
    • S. aureus and S. sobrinus in saliva
oral care as treatment
Oral Care as Treatment
  • Pneumonia, febrile days and death from pneumonia significantly decreased in patients with oral care than those without oral care

Adachi et al, Oral Surg Oral Med Oral Pathol Oral Radiol

Endod, 2002

Yoneyama et al, J Am Geriatr Soc, 2002

need for more data
Need for More Data
  • Effectiveness of oral hygiene programs in reducing aspiration pneumonia seems promising…need more high level evidence

Terpenning, Aging Infect Dis, 2005

Loeb et al, J Am Geriatr Soc, 2003

oral cancer self examination
Oral CancerSelf-Examination

NCI Surveillance, Epidemiology, End Results, 2001

30% of oral cancers originate on tongue

17% in lip

14% in floor of mouth

Resources

National Institute of Dental and Craniofacial Research

oralcancerfoundation.org

oral-cancer.org

organ preservation approaches and dysphonia
Organ Preservation Approachesand Dysphonia
  • Voice characteristics after organ preservation treatment
  • Vocal hygiene and xerostomia
  • Voice therapy
common complaints after organ preservation approaches
Common complaints after organ preservation approaches
  • Reduced pitch variability
  • Reduced ability to sing
  • Reduced loudness
  • Reduced phrase length
  • Hoarse or breathy vocal quality
  • Vocal strain
  • Vocal fatigue
organ preservation approaches and dysphonia64
Organ Preservation Approachesand Dysphonia

Videostroboscopic findings

  • Increased supraglottic tension
  • Pooling of thick secretions
  • Impaired mobility
  • Glottic incompetence
  • Irregularity of leading edge of vocal fold
  • Asymmetry and inadequate amplitude and mucosal wave
  • Fung et al, Journal of Otolaryngology, 2001
  • Meleca et al, Laryngoscope, 2003
organ preservation approaches and dysphonia66
Organ Preservation Approachesand Dysphonia

Voice Handicap Index findings

  • 27% reported significant handicap
  • Self-perceived handicap greater in younger individuals
  • Handicap increased as a function of time post-treatment
  • Fung et al, Journal of Otolaryngology, 2001
  • Meleca et al, Laryngoscope, 2003
organ preservation approaches and dysphonia67
Organ Preservation Approachesand Dysphonia

Acoustic/aerodynamic findings

  • Lower fundamental frequency for females
  • Elevated jitter and shimmer
  • Reduced MPT
  • Elevated subglottic pressure and glottal resistance
  • Fung et al, Journal of Otolaryngology, 2001
  • Meleca et al, Laryngoscope, 2003
organ preservation approaches and dysphonia68
Organ Preservation Approachesand Dysphonia
  • Mlynarek, Kost, & Gesser, Journal of Otolaryngology, 2006
    • Patients with better videostroboscopic findings after radiation alone
    • Patients with better VHI and acoustic measures after surgery
organ preservation approaches and dysphonia69
Organ Preservation Approachesand Dysphonia
  • Voice outcomes slightly better after radiation versus surgery for early glottic lesions
    • Simpson et al, Otolaryngologic Clinics of North America,1997
    • Jones et al, Head and Neck, 2004
    • Krengli et al, Acta Oncologica, 2004
  • Voice related quality of life comparable between radiation and surgery for early glottic lesions
    • Cohen et al, Annals of Otology, Rhinology, and Laryngology, 2006
    • Peeters et al, Laryngology, 2004
xerostomia and voice
Xerostomia and Voice
  • Roh et al. Journal of Clinical Oncology 2005.
    • Wide field radiation had greatest impact on salivary flow (four fold difference)
    • Increased voice disturbance (elevated but not significant)
    • Increased abnormalities under videostroboscopy (supraglottic activity, dryness of vocal folds, stickiness of secretions)
    • Reduced voice related quality of life (moderate or greater impairment on VHI)
voice therapy
Voice Therapy
  • Improve vocal hygiene
  • Improve glottic valving
  • Balance respiratory, phonatory, and resonant systems
  • Improve pliability and pitch variability
  • Reduce supraglottic constriction
  • Compensate
voice intervention
Voice Intervention
  • vanGogh et al, Cancer, 2006
    • Efficacy of voice therapy following treatment for laryngeal cancer
    • Findings:
      • Voice Handicap Index
        • Average improvement of 15 points post-treatment
      • Acoustic parameters
        • Improvement in NHR and jitter post-treatment
        • Subjective reduction in perception of vocal fry
hydration and voice
Hydration and Voice
  • Improving hydration may:
    • Reduce phonation threshold pressure
    • Reduce patient perceived vocal effort
    • Improve vocal quality
  • Solomon and DiMattia, Journal of Voice, 2000
  • Verdolini et al, Journal of Speech and Hearing Research, 1994
  • Yiu and Chan, Journal of Voice, 2003
vocal function exercises vfe
Vocal Function Exercises (VFE)
  • Holistic approach targeting balance of airflow, laryngeal musculature, and the resonant tract
  • Uses specifically trained postures for sustained phonation and pitch variation to improve balance of three subsystems
  • Described by Stemple in Seminars in Speech and Language 2005.
should vfe be beneficial following organ preservation
Voice problems after organ preservation

Reduced pitch variability

Reduced loudness

Reduced phrase length

Hoarse or breathy vocal quality

Vocal strain

Vocal fatigue

Reduced ability to sing

1, 7. Pitch manipulation (stretching/contracting) should help to improve pliability

2, 3, 4, 6. Studies are supportive of improved glottic valving after use of VFE

5, 6. Use of forward focused phonation should unload supraglottic constriction

Should VFE be beneficial following organ preservation?
vocal function exercise vfe validation
Vocal Function Exercise (VFE) Validation
  • Stemple et al, Journal of Voice, 1994
    • Randomized, double-blind placebo controlled study
    • Evaluated effects of 4 weeks of VFE in normal voice users
    • Post-treatment assessment revealed
      • Increased phonation volume
      • Decreased airflow rate
      • Increased maximum phonation time
      • Improved frequency range
    • No changes noted in the placebo or control groups
vocal function exercise vfe validation77
Vocal Function Exercise (VFE) Validation
  • Sabol et al, Journal of Voice, 1995.
    • Evaluated the impact of VFE on sophisticated voice users (opera singers)
    • 4 week treatment period
    • Post-treatment testing revealed:
      • Increased phonation volume
      • Decreased airflow rate
      • Increased maximum phonation time
    • No change in control group
vocal function exercise vfe validation78
Vocal Function Exercise (VFE) Validation
  • Roy et al, Journal of Speech, Language, and Hearing Research, 2001.
    • A prospective, randomized clinical trial comparing effects of VFE versus vocal hygiene alone
    • 6 week treatment period
    • Group receiving VFE reported an improvement in voice handicap using the VHI
    • Vocal hygiene group reported no change
    • Control group reported decline in VHI scores after 6 week period
resonant voice therapy rvt
Resonant Voice Therapy (RVT)
  • Holistic approach incorporating focus on resonance in order to balance subsystems (respiration, phonation, resonance)
  • One variant described by Verdolini, 1998: Lessac-Madsen Resonant Voice Therapy (LMRVT)
should rvt be beneficial following organ preservation
Voice problems after organ preservation

Reduced pitch variability

Reduced loudness

Reduced phrase length

Hoarse or breathy vocal quality

Vocal strain

Vocal fatigue

Reduced ability to sing

2, 3, 4, 5, 6. Improving glottic closure should improve all these parameters

1, 7. Pitch manipulation (stretching/contracting) should help to improve pliability

5, 6. Use of forward focus should reduce supraglottic strain

Should RVT be beneficial following organ preservation?
resonant voice therapy rvt validation
Resonant Voice Therapy (RVT) Validation
  • Chen et al, Journal of Voice, 2007.
  • Evaluated the impact of RVT on teachers with voice complaints (adaptation of LMRVT)
  • 8 week treatment period
  • Measures included:
    • auditory perceptual judgment
    • videostroboscopic examination
    • acoustic measurements
    • aerodynamic measurements
    • functional measurements
resonant voice therapy rvt validation82
Resonant Voice Therapy (RVT) Validation
  • Chen et al, Journal of Voice, 2007.
    • Perceptual findings
      • Improvement in roughness, strain, monotone, resonance, hard attack, glottal fry, and vocal fatigue
    • Stroboscopic findings
      • Improvement in glottic closure, mucosal wave, amplitude, and vocal pathology
    • Acoustic findings
      • Range of frequency and intensity improved
    • Aerodynamic findings
      • Phonation threshold pressure reduced
    • Functional findings
      • Significant reduction in physical subscale of VHI
circumlaryngeal massage
Circumlaryngeal Massage
  • Manual tension reduction technique
  • Includes clinician “reposturing” of the larynx during voice use
    • Compression in the a/p plane (push back)
    • Reduction in laryngeal elevation (pull down)
    • Combination of medial compression and traction
    • Circular massage over the hyoid, thyrohyoid space, posterior thyroid, suprahyoid muscles
circumlaryngeal massage validation
Circumlaryngeal Massage Validation
  • Multiple studies validate use of manual tension reduction for hyperfunctional voice users
    • Roy & Leeper, Journal of Voice, 1993
    • Roy et al, Journal of Voice, 1997
in conclusion
In conclusion
  • Patients will often report voice changes after organ preservation approaches
  • Patient perceived handicap may be higher than expected based on acoustic voice properties
  • Voice therapy should be effective… But we still need more data
cooperative care
Cooperative Care
  • Mclane et al, 2003
    • New tx model, teaches pt and care partner in homelike setting
    • Facilitated autonomy, communication and role resumption; reduced anxiety
multidisciplinary care
Multidisciplinary Care
  • Blair & Callender, 1994
    • Collaboration and communication of multidisciplinary teams have had a profound effect on the treatment of head and neck cancer
    • “Essential for positive outcomes”
qol and coping
QOL and Coping
  • Pourel et al, 2002
    • The level of symptoms and functioning was similar regardless of treatment modality
    • In long-term survivors of oropharynx ca, coping processes are most important
multidisciplinary clinics and patient satisfaction
Multidisciplinary Clinicsand Patient Satisfaction
  • Walker et al, 2003
    • Overall satisfaction predicted by younger age, female gender and greater attention to how patients were coping with illness.
supports
Supports
  • For inherent functional deficits
  • To local, national groups
  • International Association of Laryngectomees
  • Support for People with Oral and Head & Neck Cancer (SPOHNC)
  • Other head and neck cancer support groups
received vs available support
Received vs. Available Support
  • De Leeuw et al, 2000
    • Available support is beneficial regardless of situation
    • Effect of received support was equivocal
psychological distress
Psychological Distress
  • Hutton & Williams, 2001

-Trend for depression to decrease with time and to be less common among those attending a support group

uw qol organ preservation
UW-QOL: Organ Preservation

Deleyiannis FW et al. Head Neck, 1997

factors associated with worse qol
Feeding tube

Tracheostomy tube

Chemotherapy

Neck dissection

Depression

Multiple comorbidities

Tumor stage

Age

Factors Associated with Worse QOL

Terrell JE et al: Arch Otolaryngol Head Neck Surg, 2004

Karnell LH et al. Head Neck, 2006

Gourin CG et al. Laryngoscope 2005

are qol assessments accurate measures of function
Are QOL assessments accurate measures of function?
  • Post-treatment QOL improves over time- even in face of functional deficits
  • Expectations affect QOL
  • Reports are biased: what about
    • Non-survivors
    • Non-responders

Does their QOL differ?

radiation therapy and slp
Radiation Therapy and SLP
  • Involvement of speech pathologists in evaluation and treatment of patients with dysphagia can minimize swallowing difficulties and identify the tissues most responsible for swallowing. Minimizing radiation dose to these tissues may lower the incidence of radiation-induced dysphagia

Garden et. al, 2006

radiation therapy and nutrition
Radiation Therapy and Nutrition
  • Eating problems were common before treatment started, and at the end of radiotherapy every patient suffered from eating problems. One year after treatment the majority still had eating problems

Larsson et. al, 2005

slp role in organ preservation for head and neck cancers
Education

Exercises

Connections

Support

Swallowing

Voice

Speech

Oral Health

Research

Functional Outcomes

SLP Role in Organ Preservation for Head and Neck Cancers
organ preservation functional preservation
Organ Preservation ≠Functional Preservation
  • Treatment related functional impairments
  • Importance of speech-language pathology services
  • Management at Johns Hopkins
  • Current evidence