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Strategies with Head and Neck Cancer

May 07, 2008 Posted by: DiagnosTEX Educational Handouts,  Treatment and Strategies

 

 


Consultants in Dysphagia Evaluation and Management

Phone: 817-514-MBS1 or 1-888-514-MBS1
Fax: 817-514-MBS8 or 1-877-514-MBS8
Speech Pathologist Reference Sheet
By: Ronda Polansky M.S. CCC-SLP
 

 

STRATEGIES in Head and Neck Cancer
For those patients who have undergone surgical resection or organ preservation protocols for head and neck cancer and who are unable to resume functional swallowing, several treatment options are available. Treatment strategies should be introduced during the MBSS to determine the effectiveness of the strategy prior to implementation.
Several categories of interventions exist: including postural changes, sensory procedures, maneuvers, diet changes, physiologic exercise, and orofacial prosthetics. Used alone or in combination, these options can be extremely successful in returning a patient to safe and efficient oral intake.
Postural strategies are simple techniques designed to alter the bolus flow.
·        A chin down posture improves base of tongue contact to the posterior pharyngeal wall, opens the vallecular space, and puts the larynx in a more protected position.[44]
·        Head rotation to the damaged side closes off a weakened pharynx and allows bolus passage down the intact contralateral side.[45]
·        Head tilt to the intact side provides gravity assist in bolus flow through the oral cavity and pharynx. A sidelying position may be useful in a delayed swallow or with poor airway protection as it slows the flow of the bolus through the pharynx. Combinations of these strategies can be used with an additive effect.
Sensory procedures provide altered sensory feedback or sensory enhancement during swallowing.
·          Alterations in bolus volume, taste, and temperature can be used to affect changes in swallowing physiology. For example, cold and added pressure (thermal-tactile stimulation) have been shown to increase the speed of initiation of the swallow response.[46]
·        Added pressure on the tongue by a utensil also increases sensory feedback. Since chewing sends sensory information to the pharynx, a soft masticated diet should be utilized when possible.
·        Finally, the sensory motor integration achieved during self-feeding helps to normalize swallow patterns. Therefore, patients should feed themselves whenever possible.
Extensive data exist regarding the efficacy of swallowing maneuvers in the head and neck population. They are designed to alter the physiology of the swallow.
·        The supraglottic swallow maneuver closes the vocal folds before and during the swallow.[23] The effortful swallow improves tongue base retraction and pressure generation.[22]
·        The Mendelsohn maneuver enhances and prolongs laryngeal elevation and anterior movement to improve laryngeal elevation and extent and duration of cricopharyngeal opening.[22]
·        The tongue-holding maneuver improves the tongue base to posterior pharyngeal wall contact and exercises the glossopharyngeal muscle.[21]
·        Dry or repeated swallows reduce pharyngeal residues.
Diet alterations and food presentation strategies also can be use therapeutically to improve efficiency and safety of swallowing.
·        Thickening liquids may slow the rate of bolus flow through the pharynx for patients with a delayed swallow.
·        A puree diet can be used if surgical resection or trismus prevents chewing.
·        Foods prepared with sauces and gravies may be useful for a xerostomic patient.
·        Alternating solids and liquids can reduce pharyngeal stasis.
·        Liquids can be presented by cup, straw, spoon, or syringe, depending on specific patient needs.
·        Chopsticks or an iced teaspoon can place foods in the posterior oral cavity.
·        A glossectomy spoon is specially designed to push food into the pharynx, bypassing the oral phase of swallow.
Food placement on the surgically unaffected side can increase efficiency and safety as well. All of these dietary changes can be used in combination with postural alterations and swallow maneuvers at mealtime.
Oral prosthetics can offer structural support and compensation to oropharyngeal structures that were lost or altered postsurgery.
·        Palatal lowering prostheses recontour or lower the palate to allow the remaining portion of the resected tongue to contact the palate when swallowing.[47]
·        Obturators can fill a palatal defect, preventing food leakage into the nasal cavity and establishing more normal intraoral pressure.
Use of these devices can significantly reduce oral residue. The speech pathologist collaborates with the maxillofacial prosthodontist to provide feedback on the configuration, use, and benefits of the prosthesis.
 

 

 

Reference: H. Lee Moffitt Cancer Center & Research Institute, 12902 Magnolia Drive, Tampa, FL
21. Fujiu M, Logemann JA. Effect of a tongue holding maneuver on posterior pharyngeal wall movement during deglutition. Am J Speech-Lang Pathol. 1996;5:23-30.
22. Lazarus C, Logemann JA, Gibbons P. Effects of maneuvers on swallowing function in a dysphagic oral cancer patient. Head Neck. 1993;15:419-424.
23. Logemann JA, Pauloski BR, Rademaker AW, et al. Super supraglottic swallow in irradiated head and neck cancer patients. Head Neck. 1997;19:535-540.
45. Logemann JA,Kahrilas PJ, Kobara M, et al. The benefit of head rotation on pharyngoesophageal dysphagia. Arch Phys Med Rehabil. 1989;70:767-771.
46. Lazarra GDL, Lazarus C, Logemann JA. Impact of thermal stimulation on the triggering of the swallow reflex. Dysphagia. 1986;1:73-77.
47. Davis JW, Lazarus C, Logemann J, et al. Effect of a maxillary glossectomy prosthesis on articulation and swallowing. Prosthet Dent. 1987;57:715-719.