Late Oropharyngeal Dysphagia Following Head and Neck Cancer Treatment ASHA 2014 Orlando, FL

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1 Late Oropharyngeal Dysphagia Following Head and Neck Cancer Treatment ASHA 2014 Orlando, FL Vicki Lewis, M.A., CCC SLP

2 Disclosure No financial interests to disclose

3 The Disney analogy; sort of

4 Patient was referred by ENT: History included: Chronic Lymphocytic Leukemia (CLL) and small lymphocytic lymphoma of the tongue base diagnosed in In Dec.2009, the patient developed a necrotic right cervical lymph node; FNA revealed SCCA. T3N2c squamous cell carcinoma of the right tongue base was diagnosed. Underwent full dental extractions prior to treatment which were complicated by intubation injury; tracheotomy was completed. Hospitalization was prolonged and the patient underwent chemoradiation during her hospitalization. Pharyngeal and upper esophageal stenosis developed and multiple dilations were completed; a full liquid diet was initiated and upgraded over time. In 8/2011, a lesion on the right mid lateral tongue was found with pathology findings of SCCA. The patient underwent excision in 9/2011. The patient presented to our otolaryngology practice initially in 2013 with complaint of increasing dysphagia. At that time, she was taking only thin liquids by mouth.

5 What we expect to see during/after head and neck cancer treatment Expect issues during treatment due to mucositis and edema (acute toxicities) Late effects seem more related to fibrosis and cranial neuropathy (Hutcheson K et. al., 2012)

6 Patient perception of dysphagia following treatment for head and neck cancer: Patients sense a general difficulty with swallowing but have less awareness of specific symptoms of dysphagia (Rogus Pulia NM et. al., 2014)

7 Late Dysphagia Following Head & Neck CA Treatment Who is more likely to develop late swallowing issues after treatment for head and neck cancer? Mean dose of radiation to the pharyngeal constrictor muscles (Duprez F et. al., 2013) Other factors may include increasing age and chemotherapy combined with radiation therapy (Cauldell J et.al., 2009 )

8 Patient perception of Dysphagia EAT 10 A ten item outcome measure of dysphagia (rating 0 4) Score of 3 or higher is abnormal Head and neck cancer patients were included in validity and reliability testing (Mean scores: / 14.06) May be utilized to document initial dysphagia severity rating and follow ratings throughout treatment (Belafsky, PC et. al, 2008)

9 EAT 10 At initial visit: Score 10 Abnormal ratings: (#2) My swallowing problem interferes with my ability to go out for meals Score: 4 (#4) Swallowing solids takes extra effort Score: 4 (#5) Swallowing pills takes extra effort Score: 2

10 Patient Exam: Full dentures (new) were in place. Food sticks to dentures when attempting to eat. The upper plate was in place with denture adhesive and was quite large in size (not loose); The lower plate was reportedly altered. It was quite thin with minimal protrusion of teeth. (not usually worn) Trismus was evident (oral opening 20 mm) Oral mucosa was somewhat dry. Labial strength / ROM normal protrusion and retraction was within normal limits. The appearance of the tongue was remarkable for a slight defect on the left lateral border; likely consistent with the patient's resection in Lingual protrusion was mildly reduced with slight deviation to the right. Lingual lateralization to the left side was diminished. Velar elevation was symmetric and appeared to be normal. Weight loss (15 pounds) over one year.

11 Clinical Decision Making To FEES or not to FEES Patient history Radiation therapy Previous dilations for stricture Swallowing complaints Difficulty with solids

12 Videofluorscopic Swallow Study (Thin liquid)

13 Videofluorscopic Swallow Study

14 Videofluorscopic Swallow Study

15 Findings: Reduced oral control with slight premature spillage of liquids to the pharynx Reduced base of tongue retraction Mild penetration of liquids was evident during the swallow and trace to mild residue was evident in the oropharynx with thicker consistencies. No aspiration was observed The patient's degree of trismus was thought to be limiting the patient's ability to masticate thoroughly enough to resume solid consistencies There was no narrowing of the cervical esophagus, but poor motility (an adynamic segment) was evident in this area with transient delay of thicker consistencies. The residue that remained in the cervical esophagus until cleared with multiple swallows of liquid wash did recreate the patient's symptoms and an intermittent gag was evident in response to this residue

16 Treatment Trismus Oral function Dentition / dentures Oral tongue Xerostomia management Pharyngeal function Diet / Compensatory strategies Patient education Examination findings Fear ** Frustration Other issues Financial

17 Trismus Initial jaw opening (with dentures in place 20 mm What is normal MMO (maximum mouth opening)? Men: mm Women: mm Three fingers width (Zawawi KH, 2003) In the head and neck cancer literature, MMO of 35 mm has been found to be associated with perceived decrease in quality of life. (Scott B, 2008)

18 Importance of Jaw Opening Intubation Cancer surveillance Oral hygiene Dental care Bite and mastication Comfort Yawn Laugh

19 Treatment Trismus

20

21 Progress 35 MMO Full dentures in place Jul '13 Oct '13 Nov '13 Mar '14 Jul '14 Sept '14 Oct '14

22 Other areas addressed Dentition: Referral to a dental oncology specialist Findings included inappropriate denture size in order to re make dentures vertical jaw opening would need to be greater Possible dental implant placement on the lower arch to secure a lower denture plate (depending on amount of Radiation that was delivered)

23 Other areas addressed Xerostomia Management OTC products (gel, spray, lozenges, etc.) Timing of administration Oropharyngeal Exercises Maximize tongue base retraction DECLINED

24 Treatment thus far: Eat 10 Score: 6 Abnormal ratings: (#2) My swallowing problem interferes with my ability to go out for meals 3 (4) (#4) Swallowing solids takes extra effort 2 (4) (#5) Swallowing pills takes extra effort 1 (2) Trismus: 26 mm (full dentures) Diet: Soft cohesive solids with thin liquids (Eating out, but choices limited) Weight gain (17 lbs.) Persisting xerostomia

25 Take Home Messages Choosing the appropriate instrumental assessment It takes a village Education and strategies for prevention in patients we see prior to or during treatment

26 The Future HPV positive tumors Younger age at dx may survive longer following XRT Possible decrease in amount of radiation delivered Changing surgical technique / technology Trans oral robotic surgery Changes in radiation technology / delivery

27 References: Belafsky PC, Mouadeb DA, Rees CJ, Pryor JC, Postma GN, Allen J, Leonard RJ. Validity and reliability of the eating assessment tool (EAT 10). Ann Otol Rhinol Laryngol. 2008;13(12): Caudell JJ, Schaner PE, Meredith RF, Locher JL, Nabell LM, Carroll WR, Magnuson JS, Spencer SA, Bonner JA. Factors associated with long term dysphagia after definitive radiotherapy for locally advanced head and neck cancer. Int J Radiat Oncol Biol Phys Feb 1;73(2): Dall anese AP, Schultz K, Ribeiro KB, Angelis EC. Early and long term effects of physiotherapy for trismus in patients treated for oral and oropharyngeal cancer. Applied Cancer Research. 2010;30(4): Duprez F, Madani I, De Potter B, Boterberg T, De Neve W. Systematic review of dose volume correlates for structures related to late swallowing disturbances after radiotherapy for head and neck cancer. Dysphagia Sep;28(3): Hutcheson KA, Lewin JS, Barringer DA, et al. Late dysphagia after radiotherapybased treatment of head and neck cancer. Cancer Dec 1;118(23): Logemann JA, Pauloski BR, Rademaker AW, Lazarus CL, Gaziano J, Stachowiak L, Newman L, MacCracken E, Santa D, Mittal B. Swallowing disorders in the first year after radiation and chemoradiation. Head Neck. 2008;30(2): Rogus Pulia NM1, Pierce MC, Mittal BB, Zecker SG, Logemann JA. Changes in swallowing physiology and patient perception of swallowing function following chemoradiation for head and neck cancer. Dysphagia Apr;29(2): Zawawi KH, Al Badawi EA, Lobo SL, Melis M, Mehta NR. An index for the measurement of normal maximum mouth opening. J Can Dent Assoc 2003;69(11):