Speech Swallowing Preservation Protocol Amy K Mosier MS CCCSLP Regional Speech Therapy Manager SSM Rehabilitation Network Disclosures I receive a salary from SSM Rehabilitation Network I am the Vice President of Midwestern Adult Communication Disorders Group ID: 548629
Download Presentation The PPT/PDF document "Head and Neck Cancer" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
Head and Neck Cancer Speech Swallowing Preservation Protocol
Amy K Mosier M.S, CCC-SLP
Regional Speech Therapy Manager
SSM Rehabilitation NetworkSlide2
DisclosuresI receive a salary from SSM Rehabilitation Network.
I am the Vice President of Midwestern Adult Communication Disorders Group. Slide3Slide4
What causes cancers of the head and neck?! Alcohol useTobacco use
Other….Slide5
Symptoms and SignsSymptoms
Earache (referred pain)
Sore Throat/Mouth
Dysphagia, odynophagia
Epistaxis
Drooling
Changes in voice
Airway distress
Headache
Loose teeth or denture fit issuesDiplopiaFacial numbness or paresthesias
Signs
Weight loss
Hoarseness
Stridor
Aspiration
Trismus
Neck mass
Mucosal skin lesionsSlide6
The Dream Team!
Treatment Team
Physicians
ENT
Rad/Oncologist
Medical Oncologist
Radiologist
Pathologist
Supportive Services
Physical TherapySpeech and Language PathologyLymphedema TherapyDietitian
Case ManagementPsychologist Slide7
Mechanism of Radiation-Induced DysphagiaExtent of dysphagia correlates with:
Site of primary diagnosis
Size of the tumor
Extend of surgical resectionsSlide8
Swallowing Abnormalities Secondary to Radiation Therapy Most studies begin assessments at 3 month period
Abnormalities on MBS and FEES
Muscle weakness due to:
Atrophy
Loss of sensationSlide9
Radiation Therapy:Common Swallowing Abnormalities
Oral Phase
Limitations in lip closure
Loss of cheek muscles
Trismus
Tongue weakness
Spillage of bolus
Decreased sensory input
Pharyngeal Phase
Epiglottis edema
Decreased tongue base retraction
Decreased pharyngeal contraction
Decreased laryngeal elevation
Decreased anterior movement of larynxSlide10
Risk Factors for Post-radiation Swallowing Abnormalities
Dysphagia/Aspiration-related structures (DARS)
Intensity-Modulated Radiation Therapy (IMRT)Slide11
Complications of DysphagiaAspiration
Permanent or long-term feeding tube dependenceSlide12
Prevention and Treatment Critical to minimize dysphagia and its sequelae by:
understanding current standards of care
Understanding areas of ongoing investigationSlide13
Rehabilitation:The Role of Swallowing Therapy
Recommendations
Safe Swallowing Strategies
Therapeutic postures and exercises
Diet modifications
Techniques
Postural Techniques
Sensory Techniques
Motor Exercises
Swallowing ManeuversChanges in dietSlide14
Swallowing Preservation Exercises during Chemo-radiation Therapy Maintains Swallow Function
Victor M. Duarte, MD; Dinesh K. Chhetri, MD; Yuan F. Liu, Andrew A. Erman, MA and Marilene B. Wang, MD
Department of Head and Neck Surgery, David E. Geffen School of Medicine at UCLA, Los Angeles, CaliforniaSlide15
ObjectiveTo evaluate a swallow preservation protocol (SPP), in which patients received swallow therapy before, during and after radiation treatment and it’s efficacy in maintaining swallowing function in head and neck cancer patients.Slide16
RT/CRT EffectsThe overall sum of these deleterious effects leads to:D
ecreased oral caloric intake
Reliance on feeding tubes
I
ncreased morbidity
D
ecreased quality of life
Increased use of health care services Slide17
Speech/Swallow Preservation Program Goal:
Encourage patients to continue
oral intake
as much as possible, despite dysguesia and odynophagiaSlide18Slide19
Diet changeDefinition: step up or step down in diet when diets were ranked in the following order:
Chewable (regular)
Puree
Liquid
G-tube
Maintenance of diet was defined as no change in diet from pre to post treatment.
Significant difference in diet change with more of the compliant patients maintaining or improving their diet from pretreatment to 1 month post-treatment when compared to the noncompliant patientsSlide20
Diet before and after treatment No difference in pre-treatment diet between the two groups
1 month post treatment
31 of 57 patients (54.4%) compliant patients were tolerating a regular chewable diet
6 of 28 (21.4%) non compliant patients were tolerating a regular chewable diet
13 of 57 (22.8%) compliant patients were noted to be g-tube dependent
15 of 28 (53.6%) noncompliant patients were noted to be g-tube dependentSlide21
DiscussionAcute effects after RT/CRT
Patient develops mucosistis
Radiation dermatitis
Edema of the soft tissues
Which causes: pain, copious mucus production, xerostomia and tissue = DYSPHAGIA
Late effects after RT/CRT
Fibrosis
Lymphedema
Damage to neural structures manifestSlide22
Results57 patients were compliant Higher percentage of patients tolerating a regular diet(54.4% vs 21.4%,
P=
.008) and lower G-tube dependence (22.8 % vs 53/6%,
P=
.008) a higher rate of maintaining or improving their diet (54.4% vs 25.0%,
P=
.025
28 patients were non-compliant Slide23
Speech/Swallow Preservation ProgramA partnership with SSM Cancer Care & Dr. David E. Morris, Medical Director of St. Louis CyperknifeSlide24
Goals:Organ preservationQuality of life
Incorporate dysphagia program into radiation/ chemo-radiation treatment program
Focus on habilitation versus rehabilitation
Preservation Slide25
Speech/swallow preservation programSlide26
Step 1Radiation/ Chemo Radiation Therapy
Pre-treatment consultation with Dr. Morris
At that visit, Dr. Morris determines if ST is indicated.
Ancillary issues need to be addressed:
Dental Visits
Eye Exams
Speech/Swallow Preservation Protocol
No, ST indicated at this visit. Slide27
Step 2RT/CRT
Treatment Planning Session
RT/CRT time line is outlined with Dr.
M
orris
Radiation treatments typically last 10-15 minutes
SPP
Two weeks before RT/CRT treatment
Swallowing assessment
OP MBS
Treatment education
eg., expected side effects/swallow program education
Dietitian referralSlide28
Step 3RT/CRT
RT/CRT begins 1 week after planning session
Radiation Treatments
Monday-Friday
Receives RT/CRT each day of the week
20-40 prescribed treatments depending on diagnosis
Meeting with Dr. Morris once a week
SPP
Weekly Visit Include:
Diet monitoring
Encourage continued oral intake via diet log
Swallowing Exercise compliance
Based on competency during visit
Review exercises
Check exercise logSlide29
Step 4 RT/CRT
Post-Treatment meeting with Dr. Morris
Visit 2-weeks post RT/CRT Treatment
Mucositis & weight
Next visits are determined at first post RT/CRT
2-4 weeks or 2-3 month follow ups
SPP
One month after RT/CRT is completed
Diet Recorded
Exercise Education Slide30
Step 5RT/CRT
Post-Treatment meeting with Dr. Morris
If necessary per Dr. Morris
SPP
Two months after RT/CRT treatment
Diet recorded
OP MBS to compare with initial assessment
Exercise education Slide31
Exercises for SSPPSlide32
Swallowing ExercisesPerform 3 times daily except for Shaker
Gargling Liquid for 10 seconds, 10 times
Effortful swallow 10 times
Mendelsohn maneuver 10 times
Chug-a-lug, 3-ounces at once (3 oz water test)
Tongue protrusion 10 times
Tongue press 10 times
Shaker head lift 3 times (1 set a day)Slide33
Gargling LiquidGargle liquid for 10 seconds, 10 times in a rowTake small sip of water
Tilt head back, allowing the liquid to sit in the upper throat
Agitate liquid for 10 seconds with air from lungsSlide34
Hard/Effortful SwallowPURPOSE
To increase tongue base retraction and pressure during the pharyngeal phase of the swallow and reduce the amount of food residue in the valleculae of the throat.
SUPPLIES
Only saliva swallow
INSTRUCTIONS
Swallow normally nut squeeze very hard with your tongue and throat muscles throughout the swallow. Excess effort should be clearly visible in your neck
Perform this exercise 10 times, 3 times-a-daySlide35
Mendelsohn ManeuverPURPOSE
To accentuate and prolong laryngeal elevation and thereby increase the extent and duration of cricopharyngeal opening
SUPPLIES
Only saliva to swallow
INSTRUCTIONS
Swallow normally. Feel the voice box lift during the swallow
On the next swallow, feel your voice box elevating and hold it up with your neck muscles. Do not try to lift the larynx early. Let the larynx lift normally and then hold it up so that it does not drop 2-5 seconds. Complete the swallow.
Relax
Repeat 10 times, 3 times a daySlide36
Chug-a-lugPURPOSE
To practice swallowing consecutively
SUPPLIES
Cup
3 ounces of water
INSTRUCTIONS
Sit upright at 90 degrees
Do not use a straw
Drink water 3 ounces of water without stopping
Swallow in one gulp OR continuous swallows without breaksSlide37
Tongue protrusionPURPOSE
To increase tongue movement and coordination
SUPPLIES
No supplies needed
INSTRUCTIONS
Protrude tongue between lips
Sticking out tongue as far as you can
Hold tongue steady and straight for 3 to 5 seconds
Relax
Repeat 10 times in a row, 3 times dailySlide38
Tongue PressPURPOSE
To increase tongue movement and strength
SUPPLIES
Spoon, tongue depressor, popsicle stick
INSTRUCTIONS
Stick out your tongue as far as you can
Put spoon/tongue depressor/popsicle stick against tongue
Push against your tongue with the flat object at the same time as you push against the flat object with your tongue
Hold for 1 to 2 seconds
Repeat 10 times, 3 times a daySlide39
ShakerPURPOSE
To strengthen muscles of the neck in order to facilitate opening of the bottom of the throat for food passage.
SUPPLIES
None
INSTRUCTIONS
Lie flat on your back with no pillow under your head.
Lift your head to look at your toes
Hold this position for 5 seconds
Release.
Repeat 3 times, rest 1 minute between repetitionsSlide40
Implementing SPP with established RT/CRTPatient maintains swallow function
HABILITATION VERSUS REHABILITATION
Acute and IP rehab SLP’s are regionally staffed, making switching locations easier
SLPs already have expertise in this areaSlide41
Questions….