Dysphagia related to head & neck cancer intervention Colby McCurdy, MM Southeastern Louisiana University

Relevant Head & Neck Cancers Squamous Cell Carcinoma Tongue/Floor of Mouth Mandibular Laryngeal Base of Tongue/Tonsillary Differentiated from Tongue and Floor of Mouth due to unique etiology – HPV-16 225% increase in incidence from 1988-2004 (Chaturvedi et al., 2011)

Interventions: from most conservative to most invasive Chemotherapy Type and Amount Determined by Surgeon or Oncologist Radiation Therapy (XRT) Typically 35 treatments over 7 weeks Chemo + radiation Adjuvant or Concurrent Surgical Excision of Tumor (with or without adjuvant chemo) Pathology Check for Clean Margins Surgical Excision of Field Containing Tumor Surgical Excision of Field + Radiation Surgical Excision of Field + Chemo + Radiation 70% chance of ipsilateral cervical node metastasis, and a 30% chance of contralateral cervical node metastasis at the microscopic level (Choi et al., 2009; Mendenhall et al., 2011).

Effects of Chemotherapy on the swallowing mechanism and function According to the American Society of Clinical Oncology (2005), Chemotherapy typically does not result in dysphagia, but may have other side effects, including : Xerostomia Infections of the mouth or esophagus due to a compromised immune system Reduced appetite General Fatigue

Effects of radiation therapy on the swallowing mechanism and function Radiation therapy causes cell change at the level of the DNA. Therefore, cellular changes take place throughout the life span. Swallowing difficulties may begin immediately, or many years post- radiation. Side effects include (ACS, 2016): Soreness and/or open sores in the mouth or throat Xerostomia Dysgeusia Nausea Tooth decay Many pts have teeth extracted prior to treatment Mucositis Trismus Odynophagia Oropharyngeal Dysphagia Radiation Fibrosis Changes in skin texture Radiation Necrosis Tissue death

Osteoradionecrosis of the mandible. 40 YO female post-laryngectomy w/chemoradiation. Intense fibrosis in the soft tissues of the neck and stricture formation in the pharynx leading to dysphagia. Osteoradionecrosis of the mandible.

Effects of Surgical Excision on the swallowing mechanism and function Phonosurgery of TVF lesion Temporary incomplete adduction of the TVFs, resulting in incomplete airway closure Risk for aspiration Partial/Total Glossectomy Reduced sensation and ROM of the tongue, particularly on the affected side Reduced bolus manipulation and propulsion Total Laryngectomy Removal of laryngeal structures eliminates risk for aspiration, but also affects UES function because the larynx isn’t there to pull it open.

MBSS 4 years post-laryngectomy https://www.youtube.com/watch?v=4OwOOwy-214 Left partial glossectomy with forearm flap resection 

Role of the SLP in managing Dysphagia Prior to treatment, educate patient about what to expect and acquire baseline function Indirect therapy when applicable Monitor for changes in weight Make recommendations for ensuring adequate nutrition/hydration (w/nutritionist) Chemoradiation: Provide prophylactic swallow strengthening exercises and compensatory strategies for safe swallow Myofascial release oral care recommendations Ongoing dysphagia therapy during and after treatment Laryngectomy: BOT retraction exercises and compensatory strategies if applicable Re-train for taste & smell Glossectomy/FOM Resection: Lingual strengthening and ROM exercises Provide swallow strengthening exercises and compensatory strategies Work with prosthodontist for fitting of palatal drop

references American Cancer Society (2016). Side effects from radiation therapy to the head and neck. Accessed from http://www.cancer.org/treatment/treatmentsandsideeffects/treatmenttypes/radiation/understandingr adiationtherapyaguideforpatientsandfamilies/understanding-radiation-therapy-radiation-to-head-and- neck American Society of Clinical Oncology (2005). Difficulty swallowing or dysphagia. Accessed from http://www.cancer.net/navigating-cancer-care/side-effects/difficulty-swallowing-or-dysphagia Chaturvedi AK, Engels EA, Pfeiffer RM, et al. (2011). Human papillomavirus and rising oropharyngeal cancer incidence in the United States [PubMed Abstract]. Journal of Clinical Oncology, 29(32): 4294-4301. Choi WH, Hu KS, Culliney B, et al. (2009). Cancer of the oropharynx. In: Harrison LB, Sessions RB, Hong WK, eds.: Head and Neck Cancer: A Multidisciplinary Approach. 3rd ed. Philadelphia, PA: Lippincott, William & Wilkins. Mendenhall WM, Werning JW, Pfister DG (2011). Treatment of head and neck cancer. In: DeVita VT Jr, Lawrence TS, Rosenberg SA: Cancer: Principles and Practice of Oncology. 9th ed. Philadelphia, Pa: Lippincott Williams & Wilkins.