Surgical Effects on Swallowing DYSPHAGIA AFTER TREATMENT FOR HNC: WHAT CAUSES IT? WHAT TREATMENT WORKS? Surgical Effects on Swallowing

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1 Susan Langmore, PhD, CCC-SLP, BRS-S Professor, BUMC, BU September 27, 2010 DYSPHAGIA AFTER TREATMENT FOR HNC: WHAT CAUSES IT? WHAT TREATMENT WORKS? Incidence of dysphagia after XRT VA study (Wolf; Terrell and Wolf, Hillman and Wolf s) equal survival after surgery or CRT for T3-4 laryngeal cancer Huge increase in radiation therapy and chemotherapy since then Assumption: Organ Preservation better outcomes Not always true! Anatomy? Physiology Organ preservation? functional use of the organ Swallowing esp. problematic Late complications of XRT can worsen swallowing and speech after sev yrs or decades Surgical Effects on Swallowing Laryngectomy most are left with some impairment in swallowing Pharynx may act as a tube instead of a muscle UES may not open easily Taste affected Supra-glottic/ partial laryngectomy May need to learn new ways to swallow to prevent aspiration; some patients not capable of this!! Swallowing after Surgery for HNC Severity and pattern are predictable Site of resection Amount resected Type of reconstruction If flap is large/ dynamic, may impede bolus flow Progression over time Worst right after surgery and gradually improved Surgical Effects on Swallowing Tongue Oral will affect oral stage only Base of tongue may reduce bolus clearance through oropharynx Mandibular, floor of mouth Oral stage affected May affect hyoid excursion if submental muscles resected

2 Radiation Therapy has well-known adverse effects on Swallowing Early complications edema, mucositis, pain, nausea (if CT), fatigue Patient might need a feeding tube if not eating Long-term sequelae - after 3 months Swallowing, xerostomia, sticky saliva, taste, smell, chewing, trismus, tooth decay, stiffness, fibrosis, osteoradionecrosis Chemotherapy intensifies the effect of XRT What causes Dysphagia after RT? Most ( or all) of the severe swallowing problems after RT are believed due to radiation induced fibrosis Radiated tissue turns to scar tissue (fibrosis). Hard, thick tissue In some patients, it continues to grow- fibrosis replaces normal mucosa infiltrates connective tissue, muscle, cartilage Can invade nerves, bone Formation of webs, strictures; can eat away at cartilage Which Patients will have Dysphagia after CRT? Our best predictors: Stage 3 and 4 cancer Chemotherapy in addition to radiation therapy Surgery in addition to radiation therapy Patient smoked prior to - and especially, during XRT Depended entirely on feeding tube during XRT?? Patient response to radiotherapy - ideosyncratic Profile of the Dysphagia Not localized to a region All the radiated regions are affected Predominant profile = reduced ROM (stiffness) of all involved structures Changed anatomy - edema, mucosal surface changed Incidence of dysphagia after CRT no consensus Evaluation of Dysphagia MBS Study on HNC Patient Fluoroscopy (MBS) Endoscopy (FEES) Both excellent; complement each other; best if SLP Uses both tools.

3 Anatomical Changes after XRT Early edema, erythema Later fibrosis replaces normal mucosa; appearance = thick infiltrates connective tissue, muscle, cartilage Can invade nerves, bone Formation of webs, strictures EARLY AND LATE RESPONSE TO RADIATION THERAPY Results of our Survey Taken in clinicians across the US What is typical Treatment by SLPs for Patients with HNC? Most SLPs do little during XRT Except recommend diet changes Stretching fairly common Rx for all pts soon after XRT BUT for the patient with dysphagia Everything and anything tried Duration/intensity usually min/day, 7days/wk Compensatory vs Rehabilitative WHAT IS THE EVIDENCE FOR EFFICACY OF DIFFERENT THERAPIES WITH HNC PATIENTS? Compensatory Tried during the evaluation Has immediate effect Rehabilitative Usually an exercise with longer term effects

4 1. Examples of Compensatory Techniques -Modify bolus volume, consistency, viscosity. -Change method of food/liquid delivery -Modify sequence of delivery -Change rate of food/liquid delivery -Alter behavior (eg, dry/ clearing swallows, postural change) Stimulate a swallow with sensory stimulus Compensatory strategies/ interventions with HNC pts Postural changes: decreased aspiration in 75-80% HNC pts (mainly post-surgery) (Logemann et al, 94) Nothing else in the literature specific to HNC 2. Rehabilitative Techniques 1. Non-swallow strengthening exercises = task is not swallowing, but to increase strength of muscles used in swallowing 2. Swallowing maneuvers = do while you are swallowing = Have immediate effect (compensatory) Also rehabilitative? long term effect? Task specific swallow exercises? WHAT IS THE EFFECT OF NON-SWALLOW EXERCISE ON SWALLOWING IN HNC PATIENTS? Non-Swallow Exercises Tongue strengthening esp base of tongue retraction Pharyngeal squeeze/ contraction Laryngeal lifting and UES opening Goal: to strengthen these muscles so they will work better when swallowing Long term effect of Shaker s exercise (after 6 weeks of exercise) The swallow was improved in a few measures (Shaker and Easterling 97, 02, 05, 09) Positive outcomes for improving swallowing, reducing aspiration But only a minority of these patients were HNC; what is the effect for the HNC pts??

5 Aim: strengthen the tongue It did help some aspects of swallowing in CVA patients (Robbins, 2007) Lazarus, 00,06, 07 tongue strength with HNC patients at 4 time points - tongue strength always less than normals Her clinical trial (unpub?) to exercise tongue no significant effect Conclusions re: Non- Swallow Exercises with HNC patients Not enough evidence to know if they are effective in improving swallowing Mendelsohn Maneuver (Kahrilas, 91; others) WHAT IS THE EFFECT OF SWALLOW MANEUVERS ON THE SWALLOW? Focus on adams apple. As you swallow, lift the adams apple up as high as it will go and hold it up for a few seconds before letting it drop. Results in higher laryngeal elevation and overall greater amplitude of all structural movements during the swallow Supraglottic Swallow Super supraglottic swallow Logemann 97 Take a breath in, Hold your breath tight; then while keeping it held tight, swallow. Release your breath after the swallow with a cough The larynx closes at the level of the TVC before the swallow begins - protects the airway during the residual material Effortful Swallow Logemann, 90 As you swallow, squeeze your tongue and throat muscles very hard to produce a strong swallow hold onto it for a few seconds Results in better tongue base retraction and pharyngeal squeeze and overall stronger swallow

6 WHAT IS THE EFFECT OF SWALLOW MANEUVERS ON HNC PATIENTS WITH DYSPAHGIA? SWALLOW MANEUVERS HAVE SHOWN AN IMMEDIATE EFFECT IN HNC 1. Mendelsohn maneuver Lazarus 93-1 pt; Lazarus 02-3 pts) 2. SSGS (Logemann 97-9 pts; Lazarus 02-3 pts; Lazarus 93 1pt) 1. Effortful Swallow (Lazarus 02 1pt; Lazarus 02 3 pts) Freed 01 Respir Care LONG TERM EFFECTS OF SWALLOW MANEUVERS NOT KNOWN Do they have the same effect as general strengthening exercises? First article applying e-stim to dysphagia Various medical etiologies Uncontrolled study Developed Vital Stim company Aggressive marketing to everyone with unproven claims Other Studies with EStim Stroke (Ludlow 06) estim helped some patients; worsened the swallow in others Stroke RCT; no significant effect on patients (Bulow et al., 2008) Stroke - RCT (Lim et al, 2009) estim group did signif better than pts who did not get estim One published d case control study w/ H&N cancer patients (Ryu 08) Several major weakness in study design: 26 pts; enrolled within 2 weeks after treatment, tx only lasted 2 weeks; other methodologic problems, approx 1/3 pts only surgical; MBS mentioned but no data Results: Change in FDS (Functional Dysphagia Scale) score signif greater in Vital Stim group No sig diff in CDS (NOMS score) or QOL score Conclusions: Inconclusive evidence

7 Are there Alternative Therapies that Help Swallowing? Stretching Deep Tissue Massage Lymphedema therapy Nothing published no studies yet using these techniques These may be very potent in reducing fibrosis! Traditional swallow therapy in HNC Limited success No RCT with this population Patient awareness of Vital Stim - tremendous. Claims are not supported We need a clinical trial to learn whether estim helps Electrical Stimulation: A New Technique Surface electrodes on the skin overlying the submandibular or laryngeal surface As current increases, stimulates nerves underlying the skin At low levels, sensory nerves stimulated Sends afferent signals to swallow centers At higher levels, motor nerves stimulated The muscles they innervate will contract Clinical Trial: The Efficacy of Electrical Stimulation for Dysphagia in Patients with Head and Neck Cancer NIH / National Cancer Institute NIH/NCI RO1 CA ( ) Susan Langmore - (PI) Boston U Med Ctr Boston Participating Sites Boston Medical Center Core Site Brigham & Women s Hospital / Dana Farber Cancer Institute Beth Israel Deaconess Medical Center VA Boston Health Care System Lahey Clinic New York Participating Sites NYU Beth Israel Medical Center Lennox Hill Hospital New site in New Jersey soon will be participating

8 Midwest Sites Northwestern U Med Center, Chicago University of Wisconsin, Madison Baltimore Site Milton J Dance Cancer Rehabilitation Center at Greater Baltimore Medical Center Our Primary Hypothesis Swallowing will improve significantly more in patients who undergo e-stim therapy paired with swallowing exercises than in patients who have sham e-stim paired with swallowing exercises. Outcomes Improved swallowing Improved Diet Improved QOL Home Program Patient performs exercises at home Frequency/Intensity -2x/day, 6 days/week - for 3 months 2/3 of patients have estim added to exercises 1/3 of patients have sham estim added to exercises. Several Outcomes of Interest Will estim group swallow better than the exercise-only group? Estim does add benefit to therapy Will both groups improve? Exercise is the key Will neither group improve? Neither exercise or estim are beneficial

9 Conclusions Much research ongoing to determine the best treatment for dysphagia Not many answers yet!