Mario A. Landera, MA, CCC-SLP, BRS-S Clinical Instructor Dept. of Otolaryngology University of Miami Miller School of Medicine

Transcription

1 Mario A. Landera, MA, CCC-SLP, BRS-S Clinical Instructor Dept. of Otolaryngology University of Miami Miller School of Medicine

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3 Employer: University of Miami Relevant financial relationships: None Relevant nonfinancial relationships: None

4 43 year old female Conflict resolution lawyer Nonsmoker Alcoholic beverages sparingly Medical hx: Ulcerative colitis Surgical hx: Tonsillectomy Gastric Sleeve Surgery for weight loss

5 Noticed a mass along left side of neck August 2012: Saw head and neck surgeon who performed fiberoptic exam Extreme hypertrophy of lingual tonsil/base of tongue obscuring view of laryngeal inlet PET Scan Uptake in bilateral lymph nodes of the neck at levels II and III CT Scan Irregular mass in the tongue base, greater on the left side than on the right, a large mass in the left level II and III of the neck representing a conglomeration of necrotic lymph nodes measuring 2.8 cm and other smaller lymph nodes in both left and right side measuring up to 13 mm

6 September 2012: Direct microlaryngoscopy with debulking of supraglottic hypertrophy Exophytic SCC of tongue base and supraglottis T3N2cM0, Stage IVA HPV+ Combined chemoradiation recommended

7 Physician who specializes in diagnosing and treating cancer using chemotherapy Recommended Cisplatin every 3 weeks while on radiation therapy

8 Nausea Emesis Neutropenia Mucositis Lethargy

9 Physician who is trained in diagnosing and treating cancer patients using various forms of radiation 70 Gy total Given in 6 fractions a week (M-Th daily and F BID)

10 Mucositis Xerostomia Odynophagia Dysgeusia Trismus Fibrosis

11 Dryness in the mouth resulting from reduced or absent saliva flow Studies on xerostomia and swallowing have found: Reduced saliva does not correlate with slowed or inefficient swallow Reduced saliva seems to change patients perceptions of their swallowing ability and their diet perceptions (Eisbruch et al., 2001; Henson, Eisbruch, D Hondt, & Ship; Logemann et al., 2003; Logemann et al., 2001)

12 Alteration in taste Salt and bitter tastes tend to be more affected Affects QOL and desire to swallow (Baharvand, ShoalehSaadi, Barakian, & Moghaddam, 2013; McLaughlin, 2013)

13 Ototoxic monitoring Cisplatin may cause high-frequency hearing loss and/or tinnitus Baseline Audiometry Normal hearing sensitivity bilaterally Baseline Tympanometry Normal middle ear compliance bilaterally

14 Need to obtain dental clearance prior to receiving radiation to the head and neck Any questionable teeth within the field of radiation need to be removed prior to radiation to prevent infections and osteoradionecrosis Importance of oral hygiene is emphasized

15 No swallowing or speech complaints MDADI Total Score: 100 Good appetite Oral Mechanism Exam Unremarkable findings Reiterate side effects that may affect swallowing once treatment begins Discuss common strategies and exercises to help facilitate swallowing

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17 WNL Education Reiterate side effects that may affect swallowing once treatment begins Discuss common strategies and exercises to help facilitate swallowing Swallowing Therapy (Carnaby-Mann, Crary, Schmalfuss, & Amdur, 2012; Carroll et al., 2008; Duarte, Chhetri, Liu, Erman, & Wang, 2013; Kotz et al., 2012; van der Molen et al., 2011) Shown to be helpful in reducing the extent and severity of the acute toxicities impacting swallowing function Every two weeks once treatment starts Coordinated with visit to radiation oncologist

18 Masako maneuver (Lazarus et al., 2002; Fujiu & Logemann, 1996) Increases base of tongue retraction and posterior pharyngeal wall contraction Effortful swallow (Huckabee et al., 2005; Lazarus et al., 2002; Bulow et al., 2001; Hind et al., 2001) Increases oral and base of tongue motion; reduces residue post-swallow Patient instructed to deliberately increase effort when swallowing by squeezing mouth and throat

19 During second week of chemo/xrt, Adriana reports that she has begun using her PEG tube for nearly all of her nutrition mostly due to dysgeusia and odynophagia Also begins to experience abdominal pain and fever CT abdomen with contrast performed STAT PEG tube perforating liver NPO status, IV antibiotics, and admission to hospital

20 Sent to Interventional Radiology for drainage of fluid collections in the liver area via placement of drainage catheter PEG tube removed and Dobhoff tube placed for nutritional purposes MBS ordered

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22 Swallowing mechanism is functional Education Encouraged to use Biotene, Magic mouthwash mix, and pain medications (Fentanyl and Roxicet), as directed by physicians, to help alleviate odynophagia to facilitate swallowing Encouraged to take some PO at the very least Swallowing exercises, as tolerated

23 3 weeks after chemo/xrt NPO and still with Dobhoff tube Food aversion? Odynophagia Dysgeusia Spit cup MDADI Total Score: 46.32

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25 Dry heaving with thicker consistencies of barium food aversion? Mild reductions in laryngeal elevation and tongue base retraction Mild residue along valleculae Cleared with repeat swallows Swallowing mechanism is still relatively functional Education

26 Encouraged to continue using Biotene, Magic mouthwash mix, and pain medications (Fentanyl and Roxicet), as directed by physicians, to help alleviate odynophagia to facilitate swallowing Encouraged to gradually increase oral intake with at least liquid consistencies Experiment with various flavors Swallowing Exercises

27 4 weeks after chemo/xrt Still mostly NPO with Dobhoff tube Drinking small sips of water and swallowing teaspoons of yogurt Admits to being a very picky eater Encouraged to take high calorie foods that she enjoys Suggested referral to dietician and mental health

28 6 weeks after chemo/xrt Meet with dietician, but not mental health Had Dobhoff removed Swallowing high caloric supplements and shakes Dysgeusia and odynophagia reducing in severity Biggest motivation: Saw herself in the mirror looking like a crazy, disheveled woman and had to stop living like this

29 12 weeks after chemo/xrt Mechanical soft diet No odynophagia Still with dysgeusia, though able to taste better Appetite improving Supplements with 3 cans of Ensure to maintain weight MDADI Total Score: 76.84

30 Not using pain medication Mild odynophagia due to what appears to be radiation-induced ulcer along right base of tongue secondary to radiation Taste is back to being almost normal Still with some xerostomia Gaining weight Working full-time

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32 Medical oncologist Radiation oncologist Head and neck surgeon Speech Pathologist Audiologist Dentist Pathologist Dietician Mental health Radiation therapists Nurses Registration clerk Insurance verifier Valet attendants Family members

33 Baharvand, M., ShoalehSaadi, N., Barakian, R. & Moghaddam, E. J. (2013). Taste alteration and impact on quality of life after head and neck radiotherapy. Journal of Oral Pathology and Medicine, 42, Bülow, M., Olsson, R., & Ekberg, O. (2001). Videomanometric analysis of supraglottic swallow, effortful swallow, and chin tuck in patients with pharyngeal dysfunction. Dysphagia, 16, Carnaby-Mann, G., Crary, M. A., Schmalfuss, I., & Amdur, R. (2012). Pharyngocise : Randomized controlled trial of preventative exercises to maintain muscle structure and swallowing function during head and neck chemoradiotherapy. International Journal of Radiation Oncology Biology Physics, 83, Carroll, W. R., Locher, J. L., Canon, C. L., Bohannon, I. A., McColloch, N. L., & Magnuson, J. S. (2008). Pretreatment swallowing exercises improve swallow function after chemoradiation. The Laryngoscope, 118, Duarte, V.M., Chhetri, D. K., Liu, Y.F., Erman, A.A., & Wang, M.B. (2013). Swallow preservation exercises during chemoradiation therapy maintains swallow function. Otolaryngology--Head and Neck Surgery. Advance online publication. Eisbruch, A., Kim, H.M., Terrell, J.E., Marsh, L.H., Dawson, L.A., & Ship, J.A. (2001). Xerostomia and its predictors following parotid-sparing irradiation of head and neck cancer. International Journal of Radiation Oncology Biology Physics, 50, Fujiu, M., & Logemann, J. A. (1996). Effect of a tongue holding maneuver on posterior pharyngeal wall movement during deglutition. American Journal of Speech-Language Pathology, 5, Henson, B.S., Eisbruch, A., D Hondt, E., & Ship, J.A. (1999). Two-year longitudinal study of parotid salivary flow rates in head and neck cancer patients receiving unilateral neck parotid- sparing radiotherapy treatment. Oral Oncology, 35,

34 Hind, J.A., Nicosia, M.A., Roecker, E.B., Carnes, M.L., & Robbins, J. (2001). Comparison of effortful and noneffortful swallows in healthy middle-aged and older adults. Archives of Physical Medicine and Rehabilitation, 82, Huckabee, M.L., Butler, S.G., Barclay, M., & Jit, S. (2005). Submental surface electromyographic measurement and pharyngeal pressures during normal and effortful swallowing. Archives of Physical Medicine and Rehabilitation, 86, Kotz, T., Federman, A. D., Kao, J., Milman, L., Packer, S., Lopez-Prieto, C., Forsythe, K., & Genden, E. M. (2012). Prophylactic swallowing exercises in patients with head and neck cancer undergoing chemoradiation: A randomized trial. Archives of Otolaryngology- Head and Neck Surgery, 138, Lazarus, C. L., Logemann, J. A., Song, C. W., Rademaker, A. W., & Kahrilas, P. J. (2002). Effects of voluntary maneuvers on tongue base function for swallowing. Folia Phoniatrica et Logopaedica, 54, Logemann, J.A., Pauloski, B.R., Rademaker, A.W., Lazarus, C.L., Mittal, B., Gaziano, J., Stachowiak, L, MacCracken, E., & Newman, L.A. (2003). Xerostomia: 12-month changes in saliva production and its relationship to perception and performance of swallow function, oral intake, and diet after chemoradiation. Head and Neck, 25, Logemann, J.A., Smith, C.H., Pauloski, B.R., Rademaker, A.W., Lazarus, C.L., Colangelo, L.A., Newman, L.A. (2001). Effects of xerostomia on perception and performance of swallow function. Head and Neck, 23, McLaughlin, L. (2013). Taste dysfunction in head and neck cancer survivors. Oncology Nursing Forum, 40, E4-E13. van der Molen, L., van Rossum, M. A., Burkhead, L. M., Smeele, L. E., Rasch, C. R., & Hilgers, F. J. (2011). A randomized preventative rehabilitation trial in advanced head and neck cancer patients treated with chemoradiotherapy: Feasibility, compliance, and short-term effects. Dysphagia, 26,