Swallowing Disorders: Head & Neck Cancer

Question 1

How has head and neck cancer treatment evolved?

Answer 1

Radiation Therapy(RXT) has surpassed surgery in frequency.

Assumption is that organ preservation = better outcomes (Not always true for swallowing)

Problem is that it attempts to preserve the organ, but not often the function of the organ.

The addition of Chemotherapy doubles the mucosal toxicity.

Question 2

What is the incidence of dysphagia in H&N cancers?

Answer 2

34%-77% in first 90 days

9%-50% in 2 years

10-12 years post radiation, patients are coming back in and their swallowing is horrible! Between 1-10 they’re doing pretty well, then after 10 years their swallow significantly deteriorates. They’re not quite sure why.

Aspiration= 22%-89% after RXT/Chemo

Question 3

What does RXT stand for?

Answer 3

radiation

Question 4

what are some things radiation can damage?

Answer 4

skin

mucosa

vascular tissue

connective tissues

muscles

salivary glands

bone

nerves

teeth

Question 5

What are some “early changes (up to 90 days)” due to radiation?

Answer 5

Mucositis: Pain, erythema, edema, ulceration, with decreased saliva.

oReally painful for patients. Mucosa lining of your mouth and throat gets infected.

Swallowing: Pain, decreased saliva, thick saliva, taste changes

Question 6

What are some “late changes (up to 90 days)” due to radiation?

Answer 6

Increase in collagen/fibrosis of connective tissueà Loss of elasticity/narrowing of structures

May benefit from stretches, increasing range of motion, Trismus exercises…

It can involve muscleà muscle necrosis, atrophy (can continue for 10 years)

It can involve bone, nerveà it may appear several years later

Osteoradionecrosis: where the bone necrostasises it becomes brittle

Trismus

Decreased laryngo-pharyngeal sensation

Continued xerostomia→Worst complaint of most of the patients

Question 7

What do we often see from pt.s w/ H&N cancer?

Answer 7

Edema/Lymphedema

Formation of webs/strictures (especially in the esophagus and at the vocal fold level)

Structures eroded

Reduction of lateral channels around the larynx because of thickened pharyngeal walls and thickened epiglottis (everything gets really swollen, not a lot of room for food to clear—leading to residue.)

Impairment of pharyngeal strength

Decreased hyolaryngeal elevation

Decreased CP opening

Decreased base of tongue motion

Decreased bolus clearance

Esophageal dysfunction

Question 8

What is lymphedema?

Answer 8

Abnormal collection of protein-rich fluid in the interstitium resulting from obstruction of lymphatic drainage. Can cause pain, decreased movement, swelling, & stiffness. Characterized by puffiness and “pitting”.

Question 9

What is fibrosis?

Answer 9

Damage to the skin and subcutaneous tissue. Characterized by hardened, stiff, dense tissue.

Question 10

What is the treatment for lymphedema & fibrosis?

Answer 10

Many rehabilitation facilities have lymphedema specialists (Physical Therapists usually)

They may treat lymphedema with massage (lymphatic drainage & wrapping)

Fibrosis is usually treated with a “deeper” massage to break up the fibrotic tissue. Myofascial release is a good option as well.

Speech Therapists are beginning to become trained in both of these to some degree.

vital stim doesn’t work—its been debunked for head and neck cancer patients… Lymphedema massage, fibrotic massage, and myofascial release are the wave of the future for head and neck cancer patients.

Question 11

What are some key concepts about radiation?

Answer 11

XRT/Chemotherapy ALWAYS hinders swallowing

Tongue, epiglottis, and UES are key in XRT

Must work with the patient before, during, and after XRT/chemotherapy

Question 12

Describe the vicious cycle of dysphagia & radiation…

Answer 12

Dysphagia may lead to weight loss and negative effects on swallowing function

Weight loss may lead to XRT interruption

XRT interruption leads to decreased survival

Decreased immune system function

Question 13

What are some solutions to dysphagia due to H&N cancer?

Answer 13

Shielding

Modifying method, manner, or composition of intake

Best is to try and KEEP SWALLOWING!!!!!

Exercises—good for breaking fibrosis

• Jaw ROM
• Active exercises (Use it or lose it!)

Question 14

What are some things we can do pre-radiation?

Answer 14

Scott likes to perform a clinical swallowing evaluation prior to starting radiation/chemo.

Is the CA or tumor causing dysphagia?

Are they safe?

What is the baseline of his/her swallow?

Do they know what to expect with radiation/chemo?

Question 15

What are possible effects of radiation on swallowing?

Answer 15

1. Xerostomia
2. Pharyngeal Residue
3. Aspiration
4. GER
   * See handout*

Question 16

What are the main cancers we see with H&N cancers?

Answer 16

Epiglottic cancer

Tonsillar cancer

Smoking, chewing tobacco, and nowadays the big cause is the HPV virus.

Question 17

What are some oral phase problems laryngectomees may have ?

Answer 17

Xerostomia!

Loss of dentition

Actual cancers of the oral structures

Effects of surgery for removal of oral cancers

Trismus

Odynophagia

Be aware that taste (many times) has been lost.

Question 18

What are some oral transit phase problems laryngectomees may have ?

Answer 18

Xerostomia!

Actual Cancers of the oral structures including base of tongue

Effects of surgery for removal of caner (ie., Glossectomy)

Odynophagia

Question 19

What are some pharyngeal phase problems laryngectomees may have?

Answer 19

There should be no reason that a pt. with a laryngectomy would be aspirating…unless there is a fistula or they aspirate through the stoma (ie., shower)

Typically, the problems laryngectomees experience with swallowing have to do with scarring and/or radiation effects

Many times, the epiglottis has been reconstructed (pseudoepiglottis)

The C-P may be “tight” from fibrosis as a result of radiation causing poor entrance of bolus into esophagus (Esophageal speech—the vibratory source is the CP sphincter)

Fibrosis and lymphedema are common

Question 20

What are some esophageal phase problems laryngectomees may have?

Answer 20

Chemo and/or XRT can exacerbate or cause reflux and other GI issues (stenosis)