Swallow Study and the Laryngectomy Patient Long Term Dysphagia after Treatment for Head and Neck Cancer

Transcription

1 Swallow Study and the Laryngectomy Patient Long Term Dysphagia after Treatment for Head and Neck Cancer Angela Campanelli, MS, CCC SLP Board Certified Specialist in Swallowing and Swallowing Disorders ASHA November 16, 2014

2 Financial Disclosure I have no relevant financial or non financial relationships to disclose. I am an employee of The Blaine Block Institute for Voice Analysis and Rehabilitation which pays my salary. Contact Information: acampanelli@soents.com

3 DR. JERI LOGEMANN We are not the handmaidens to the physician.

4 Introduction Long Term Dysphagia after Treatment for Head and Neck Cancer Laryngectomy can be a primary treatment for cancer of the larynx/pharynx, a salvage procedure post CRT due to recurrence, or necessary to restore function after post CRT effects result in a non functional larynx. Studies as early as 1965 describe dysphagia in the laryngectomy population

5 Changes in Cancer Therapy: Changes What We See and How it Works Surgical Closure Procedures Jejunal interposition/gastric pull up Vertical closure may create redundant tissue Filling Surgical Defects Pectoralis flap repair Antero lateral thigh free flap repair pharynx Radial forearm free flap repair pharynx

6 Common Findings in the Laryngectomy Stricture 19 33% Pseudo epiglottis is redundant tissue from the closure Diverticulum is an out pouching. Leakage/Aspiration Around prosthesis Through prosthesis

7 Leakage Around Pistoning of a too large prosthesis Enlarged Puncture Tract Risk Factors (Hutcheson, K et.al, 2011) Advanced nodal disease (x4) Post operative proximal stricture (x3) Locoregional recurrence or Distant Metastasis (x6)

8 PE Segment: Voice and Swallowing The referring clinician and surgeon have more concerns than food transit. Treatment/intervention is dependent on Is it spasm, stricture, or narrow? Consider the Dual Function Lumen/neo pharynx is a pathway for food and liquid to travel so some optimal opening must exist for liquid and food transit This opening must have some degree of resistance/tone in order to generate sound

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10 Choosing Radiographic Contrast Consider extravasation vs. aspiration. Barium Preferred if high leak/aspiration risk Will lodge forever in tissue Omnipaque and Gastrografin Are toxic to the lungs Are absorbed by tissue Are a nectar thick consistency; may miss fine tissue areas of breakdown

11 Case #1 Frequent TEP Change; Leaks Around and Through 51 year old male, Stage IV T4aN2cM0; 8x5x1 cm posterior oro and hypo pharynx extending tonsillar area to upper level of thyroid cartilage, 8/2012 Total laryngectomy circumferential pharyngectomy; anterolateral thigh graft repair with hypoglossal cable graft using vastus lateralis 9/2012 Radiation after surgery

12 LEAKAGE Medscape. Lori E Lombard, PhD Professor, Department of Special Education and Clinical Services, Indiana University of Pennsylvania

13 Case #1 History Frequent TEP changes due to leakage Initially leakage around due to need to size down Biofilm was evident, then treated, new TEP After all that was addressed patient reported intermittent leakage starting 2 weeks post change, but he wore that Indwelling TEP for six months Ordered Barium swallow 3/2013

14 Case #1 VFSS 4/2013 Voicing and Swallow Intelligible and audible, fluent TEP speaker He complained of muffled voice that therapist would characterize as damping He denied dysphagia but avoided some meats and used liquid rinse Left lingual paralysis, chewed on the right

15 Case #1 Video Clip Varibar Thin Liquid swallows some residual 13 mm tablet stasis of about 5 seconds Other findings: Thin liquid leakage via TEP center noted after the study Varibar pudding contrast and graham cracker 20% stasis that cleared with liquid rinse

16 Case #1 Pill Challenge

17 Case #1 After the VFSS 8/2014 dilated to 45 Fr. by Head and Neck Surgeon Was given tapered bougie for self dilation Indwelling TEP from 6/2014 still in place 11/2014 TEP change visit He reported no change except increased leaking through the TEP right after dilatation and increased again mid October Once daily self dilation resulted in less choking/leakage after daily dilatation with compliance for one week (prescribed twice/day) TEP covered in bio film (had been eradicated for one year with Nystatin) Resized with noted new granuloma (was a 12, then 10, then 8, now 12 mm all 16 Fr)

18 Case #2 Spasm vs. Narrowing Pharyngeal? Esophageal? 77 year old male Stage IV T3N1Mo SCC of left aryepiglottic fold, pyriform sinus, ventricular fold, and base of tongue, invading skeletal muscles 12/2010 total laryngectomy, left neck dissection, TEP 2/2011 Completed radiation 6 Gy, 5/2011 New 7 mm nodule right suprahilar, new RUL 2mm nodule per PET, 8/2011

19 Case #2 History Reporting dysphagia to his therapist with solid and liquid regurgitation Esophageal dilatation done ~8/2013, 48Fr Maloney dilator New onset of soft voice Return of dysphagia, choosing mechanical soft, ground meats, any liquid Fitted with a pressure band for voice, 9/2013

20 Case #2 VFSS 10/2013 Voicing and Swallowing Intelligible, fluent TEP speaker with Voice Pressure Band in place (3 buttons stacked and hand sewn on a Velcro clasped strip of fabric) I had a good voice until 2 months ago. Had a month of therapy for lingual, base of tongue strengthening and effortful swallow The food won t go down. It just comes out my nose. Complains of severe night time G E reflux on H2 blocker

21 Case #2 Video Clip Wearing Voice Pressure Band Varibar Thin Liquid Note pseudo valleculae Note diverticulum like post op space posterior to that Slow clearance above Voice Pressure Band

22 Case#2 Voice Pressure Band

23 Case #2 Video Clip Voice Pressure Band removed Varibar Pudding Varibar Thin Liquid readily cleared Graham cracker at the end minimal regurgitation

24 Case #2 No Voice Pressure Band

25 Case #2 Post Video Lung metastasis 2014 Not voicing Leaking around and through the prosthesis therefore Large Esophageal Flange/Large Tracheal Flange prosthesis placed, 3/2014 Now must use small bolus, gentle swallow to prevent leaking around

26 Case #3 Surgeon Asks Stricture? Extravasation? 80 year old male had a total laryngectomy and TEP in 1984; hypertonic PE segment using electrolarynx for several years Multiple recurrences Patient really wants to eat Quality of Life issue surgeon refers for exam

27 Case #3 History GI notes indicate patient all oral, dysphagic complaints; EGD with dilatation planned, 8/2009 Base of tongue recurrence with radiation; esophageal dilatation, 2009 Submandibular pain prompted referral and flexible endoscopy revealing open PE segment, 2010 More radiation to BOT, gastrostomy tube placed due to inability to swallow 2011 FEES complete inability to clear secretions, 2011

28 Case # 3 VFSS 2014 Voicing and Swallowing NPO for 2 years He is writing to communicate, and mouthing words as neck rigidity no longer able to use electrolarynx effectively

29 Case #3 Video Clip Gastrografin 3 cc presented Maximal cues for effortful swallow throughout the exam Findings: apparent high grade stricture

30 Case #3 Worst Case Scenario

31 Case #3 Post Video Peri stomal recurrence with fistula, 2014 No longer tolerating or responding to chemotherapy. This fighter died from complications of recurrent head and neck cancer in August His perseverance, and his intelligent, kind, and playful demeanor lives on in our memories.

32 VFSS Procedural Suggestions Be systematic. Know your patient. Views lateral, A P, and oblique for initial contrast which is thin/gastro/omnipaque Bolus size: 3, 5 cc, then 10 or cup Increase to nectar, honey, puree as needed with metered bolus size Solids next 13 mm Barium Tablet if lumen appears adequate

33 VFSS Measures Examine the degree of neo pharyngeal opening How many swallows to pass liquid Time and % of clearance of puree/solid Is that enough to safely give 13 mm tablet? Examine compliance can it stretch/contract; is it spasming

34 Final Thoughts In the organ preservation era, post radiation changes necessitate removal and reconstruction of the pharynx. Review the operative report. Report changes to the surgeon. Keep the idea of recurrence/new cancer in the back of your mind when fistula s and changes in function/tissue occur.

35 Physiological Considerations Tongue initiates driving pressure through the pharynx (Kronenberger, et al; 1994) Oral thrust delivering the bolus into the esophagus played a greater role than gravity in accelerating the bolus. Effortful swallow??? (Curtis J et al Normal solid bolus swallowing erect position. Dysphagia 1: GW University Medical Center/Naval Hospital Bethesda)