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124 Cards in this Set
- Front
- Back
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What is cancer? |
Cell growth that is out of control |
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Hyperplasia |
Out of control cell growth |
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Ways that abnormal cells may travel: |
1) Metastasis 2) Via blood system 3) Via lymph system |
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General cancer warning signs** |
1) Unexplained weight loss 2) Fever 3) Fatigue 4) Pain |
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Specific cancer warning signs** |
1) Changes in bowel or bladder function 2) Sores that do not heal 3) Unusual bleeding or discharge 4) Thickening or lump in any part of the body 5) Indigestion or dysphagia 6) Recent changes in wart or mole 7) Nagging cough or hoarseness |
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ORAL cancer symptoms |
1) Lump or thickening of cheek
2) White or red patch on gums, tongue |
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NASAL and HYPOPHARGYNEAL cancer symptoms |
No early sx! |
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SUPRAGLOTTIC cancer sx |
1) Pain on swallow
2) Globus neck mass often present |
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GLOTTIC cancer sx |
Hoarseness, stridor, or airway obstruction
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SUPRAGLOTTIC cancer sx
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Hoarseness, airway obstruction |
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Specific problem variables |
1) Size and site of lesion 2) Types of treatment offered and intensity 3) Degree and extent of surgical reconstruction 4) Reconstruction techniques used 5) Side effects of medical treatment 6) Patient factors - response |
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What is the most common result of head and neck cancer and ablative treatments used for cancer? |
Dysphagia |
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What percentage of H&N cancer pts get dysphagia? |
>60% |
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TNM** |
T: Tumor N: Neck lymph node involvement M: Metastasis |
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How many TNM stages are there? |
I-IV |
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What do the stages in TNM stand for? |
5 year survival predictions following treatment |
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3 Main Types of Cancer Treament |
1) Surgery 2) Radiation 3) Chemotherapy |
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Common side effects of Tx |
1) Infection/inflammation 2) Saliva Issues/Xerostomia 3) Pain 4) Swallowing 5) Voice/speech 6) Nutrition/Appetite 7) Taste/smell 8) Movement/flexibility 9) Psychological adjustment |
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Surgical options for H&N cancer |
1) Primary tumor surgery 2) Mandibulectomy 3) Mandibulotomy 4) Maxillectomy 5) Moh's Surgery (3 sides) 6) Laser Surgery 7) Laryngectomy 8) Trach & gastrostomy 9) Reconstructive surgery |
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Why are pt's trached and have gastrostomy tubes after surgery? |
Because of the swelling |
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Surgical Side Effects** |
1) Swelling in mouth/throat impairing respiration 2) Impaired speech/voice 3) Difficulty chewing/swallowing 4) Facial disfigurement 5) Numbness in face, neck, throat 6) Reduced mobility in shoulder, neck area 7) Decrease thyroid function |
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Surgery-Related Swallowing Deficits (Overview) |
1) Partial glossectomy 2) Total glossectomy 3) Anterior/Lateral FOM 4) Tonsil / BOT 5) Pharyngeal resection 6) Hemilaryngectomy 7) Supraglottic laryngectomy 8) Total laryngectomy 9) Motor deficits |
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Deficits related to Partial Glossectomy |
1) Difficulty holding & preparing a bolus for swallow |
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Deficits related to Total Glossectomy |
1) Difficulty moving materials from mouth to pharynx 2) Reduced lingual driving force 3) May show reduced pharyngeal clearance 4) "Pocketing" of food residue in oral cavity |
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Anterior FOM Deficits |
1) Reduced labial closure/abnormal hold 2) Reduced lingual control 3) Delayed pharyngeal swallow 4) Fewer problems if tongue is mobile |
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Lateral FOM Deficits |
1) Reduced tongue control/bolus hold 2) Reduced chewing ability (can't lateralize) 3) Aspiration before swallow 4) Reduced pharyngeal propulsion 5) Tongue sutured into deficit- worse outcome |
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Tonsil/BOM Deficits |
1) Reduced lingual control (premature entry of liquids, delayed entry of solids) 2) Delayed pharyngeal swallow 3) Reduced pharyngeal constriction 4) Reduced tongue base retraction 5) Reduced tongue to palate squeeze 6) Nasal regurgitation |
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Pharyngeal Resection Deficits |
1) Reduced pharyngeal constriction 2) Premature entry of fluids 3) Reduced force of swallow 4) Reduced clearance (all due to less muscle force) |
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Hemilaryngectomy Deficits |
1) Reduced airway closure 2) Unilateral pharyngeal weakness |
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Supraglottic laryngectomy Deficits |
1) Reduced closure laryngeal vestibule 2) Reduced airway closure 3) Reduced pharyngeal peristalsis |
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Total Laryngectomy Deficits |
1) Mainly motility issues and mechanical deficits Scar, stricture, web, fistula, PES dysfunction, poor esophageal motility |
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Three types of radiation |
1) Curative 2) Combined 3) Palliative |
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Internal Radiation |
Implant therapy Radioactive materials placed near tumor |
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External Radiation |
Usually given in curative dose prior to other therapies Smaller dose used in combination with surgery 4-6 weeks post-surgery |
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Complication of RT in H&N Cancer contributing directly to dysphagia** |
1) Mucositis 2) Xerostomia 3) Taste/Smell losses 4) Fibrosis 5) Neuropathy 6) Stricture 7) Pain 8) Odynophagia 9) Loss of appetite 10) Edema |
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Acute Toxicity Side Effects |
1) Skin redness/irritation 2) Xerostomia 3) Fatigue 4) Dry cough 5) Sore throat (mucositis) 6) Nausea/Vomiting 7) Dysphagia |
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Chronic Toxicity Side Effects |
1) Mucosal fibrosis and atrophy 2) Xerostomia 3) Dental caries 4) Fungal infections 5) Weight loss |
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Extra Chronic Toxicity Side Effects (Late Late) |
1) Tissue necrosis 2) Taste dysfunction 3) Dysphagia |
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Oropharyngeal Dysphagia Probs post RT** |
1) Bolus control deficits 2) Dry mouth 3) Pain 4) Altered Taste |
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Reasons for swallowing problems in mucosal tissue changes |
1) Xerostomia 2) Mucositis 3) Edema 4) Infections |
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Reasons for swallowing problems in muscle tissue changes |
1) Edema 2) Fibrosis 3) Neuropathy |
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Dysphagia-Later Problems |
1) Mechanical obstruction 2) Secretion management 3) Xerostomia 4) Stricture 5) Trismus 6) Fibrosis 7) Malnutrition 8) Dental caries 9) Soft tissue necrosis |
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T/F: Post-radiation swallowing problems are more common than in surgery |
True |
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SLP dysphagia assessment in HNC |
1) Multifactorial assessment 2) Assess impact factors- pain, dryness, taste/smell, fibrosis, nutritional status, psych issues |
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Clinical Dysphagia Assessment in HNC |
1) History- med status, complaints 2) Clinical observations 3) Physical swallowing exam (cervical ascultation) 4) Swallowing trials (if appropriate) 5) Impact factors 6) Patient counseling (HRQOL) |
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Info for Clinical History |
1) Type of cancer- site, size, position 2) First noticed- symptoms 3) Time until diagnosis 4) Pt report of feeding/swallowing probs 5) Family report of feeding/swallowing probs 6) Strategies/treaments tried 7) Smoking/drinking 8) History of pneuonia 9) Comorbidities 10) Rx history |
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Specific items to address in HNC eval |
1) Ability to follow directions 2) Mouth and dentition status 3) Oral motor exam (secretions, volitional cough, etc.) 4) Condition of neck musculature 5) Voice characteristics 6) Taste & smell 7) 3 day dietary record 8) Height/weight record 9) Swallowing QOL |
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Trial Swallowing |
1) Range of materials given 2) Oral transit - estimate of delay 3) Total swallow duration - estimate 4) Laryngeal elevation - palpate 5) Voice quality after swallow 6) Secretions after swallow 7) Swallow per bolus 8) Estimate of aspiration |
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Feeding & Swallow Measures |
1) HRQOL 2) WHO Musositis Scale (pain & dysphagia) 3) UM Xerostomia Scale 4) Therabite ROM scale 5) MD Anderson Dysphagia Index (MDADI) 6) MD Anderson Symptom Index (MDASI) 7) Sydney Swallowing Questionnaire (SSQ) |
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T/F: Dysphagia is common during and follwoing HNC treatments |
TRUE |
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T/F: Dysphagia may be present before HNC treatments |
TRUE |
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Swallowing is ________, |
A highly integrated process of moving food, liquid, and saliva through the upper aerodigestive tract |
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Swallowing is described in stages, but really _______. |
What happens in one stage affects another |
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Esophagus |
- Distensible tube, 10", 21-27 cm - Collapsed at rest, distensible up to 3 cm |
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Types of muscle in the esophagus |
1) Striated - voluntary 2) Smooth 3) Mixed |
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Type of muscle in the proximal esophagus
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1) Striated - voluntary Innervated by RLN and symphatetic plexus |
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Type of muscle in distal esophagus |
1) Smooth - involuntary Innervted by autonomic input |
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Muscular Layers of Esophagus |
- 2 Layers - Inner circular fibers - Outer longitudinal fibers |
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Peristalsis |
Orderly ring-like muscular contractions that push material through the esophagus |
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Primary Peristalsis |
Initiated when bolus enters esophagus |
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Secondary Peristalsis |
Initiated by bolus distension of esophagus at specific locations |
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Tertiary Contractions |
- Not peristalsis - May disrupt bolus - Contractions occur simultaneously at various points |
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How is peristalsis measured? |
HRM: High Resolution Manometry |
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How do pharynx and esophagus interact during swallow? |
Highly interactive Secondary swallow can disrupt peristalsis |
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Four types of Esophageal Dysphasia |
1) Structural disorders 2) Motility disorders 3) Lower esophageal spinchter abnormalities 4) Disorders of the PES |
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Structural Disorders |
1) Stenosis 2) Luminal deformity 3) Diverticulum |
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Motility Disorders |
1) Disorders of Peristalsis 2) Nonspecific disorders |
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Lower Esophageal Spinchter Abnormalities |
1) Achalasia 2) Isolated LES abnormalities |
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Disorders of the PES |
1) CP Bar 2) Zenker's Diverticulum |
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Anatomic Stenosis |
- Structural disorder - Usually noticed with foods (solid, fibrous foods or absorbent foods like bread) - Not liquids - 18-20 mm not symptomatic - 10-12 mm always symptomatic - Causes: mucosal rings, benign strictures, malignant tumors - Assessment: Radiopaque pill swallow - Treatment: Dialation |
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Stenosis: Rings and Webs |
- Bands of mucosal and submucosal tissue - Rings at G-E junction - Webs elsewhere - Intermittent solid food dysphagia - Treatment: dialation |
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T/F: Webs in PES and cervical esophagus are usually benign |
TRUE |
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Schatzki's Rings |
- Most common - Band-like constrictions - Always associated with hiatal hernia (but not reverse) - Unknown etiology |
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Stenosis: Benign Strictures |
- Narrowed esophageal segment >1 cm - Secondary to esophagitis - May be from GERD, trauma, drug-induced (pills get stuck and dissolve at level of aortic arch) - Progressive solid food complaints, maybe thick liquids - Treatment: Dilatation |
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Stenosis: Malignant Strictures |
- Solid AND liquid dysphagia (liquid dysphagia comes on FAST) - Treatment: Esophagectomy - Treatment: Palliative care >5% survival rate at 5 years |
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Surgical Management for Esophageal Cancer |
1) Esophagectomy 2) Gastric pull-up 3) PEG tube |
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Stenosis: Luminal Deformity |
External compression of the esophagus due to tumor, aortic arch, cardiomegaly, etc. Usually asymptomic because contralateral wall is elastic Treat by trying to remove the cause |
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Diverticulum |
- Luminal deformity - Outpouching of the esophagus - Rare compared to hypopharyngeal diverticulum - Small, usually asymptomatic - Liquid and solid dysphagia, regurgitation into mouth - Commonly caused by esophageal blockage below the bolus, causes esophageal bulging - Pulsion: High intraluminal pressure on weakened esophageal walls - Treatment only when symptomatic and aims to treat high intraluminal pressures |
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Disorders of peristalsis causes |
1) Contraction amplitude too high or too low 2) Contraction duration is prolonged 3) Contraction pattern is uncoordinated Most common cause is esophageal irritation, GER |
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Disorders of peristasis symptoms |
- Dysphagia for solids and liquids - Chest pain and regurgitation - Diffuse esophageal spasm (high pressure and incomplete relaxation) - Nutcracker esophagus: High manometry amplitudes, chest pain, normal esophagram |
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Achalasia |
- Failure of LES to relax - Dysphagia for liquids and solids - Late food regurgitation (hours after) - Variant: Vigorous achalasia- pronlonged, high amplitude contraction of the esophagus - Treatment: Calcium channel blockers (smooths muscle), dialation, surgery (myotomy), botox |
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Motor Weakness |
- Severe esophageal weakness is rare
- Common in people with scleroderma, diabetes, alcohol, medication side effects |
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Reflux - GER |
- Normal, physiologic reflux - Normal movement of gastric contents into esophagus - Common and normal due to constant changes in pressure relations - Relaxation of LES is brief and refluxate is immediately cleared |
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GERD |
- When gastric contents entering esophagus are not immediately cleared, or transient relaxations are frequent, leading to symptom development - Symptoms: Heartburn - May or may not cause esophagitis - May cause esophageal dysmotility - May cause cervical symptoms (globus) secondary to esophageal dysmotility |
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GERD Assessment |
- 24 probe (acid <4.0 is abnormal) - EGD: Performed by GI physicians under sedation, looks for consequences of GERD -TNE: Transnasal esophagoscopy: Can be performed in office by an ENT - Manometry |
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GERD Treatment |
Lifestyle Changes Medication Surgery Aims: - Enhance the antireflux barrier - Improve esophageal clearance and emptying - Decrease noxiousness of gastric contents |
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LPR (Larygopharyngeal Reflux) |
- Reflux contents reach the laryngeal level - Differs from GERD, - Most events in the day - Require higher medication doses to control |
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Symptoms of LPR |
- Globus - Hoarseness - Chronic cough - Laryngitis/pharyngitis - Cancer |
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Assessment of LPR |
- Nasopharyngeal pH probe - Reflux Sympton Index: RSI - Reflux Finding Score: RFS |
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PES Abnormalities Causes |
- Bars (posterior) - Webs - Diverticula (pharyngeal pouches) - Weakness (reduced opening, early closure) |
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T/F: Many patients reporting solid dysphagia at the level of the lower neck (cervical esophagus) have esophageal disorders |
TRUE Solid food dysphagia, think ESOPHAGUS |
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Zenker's Diverticulum |
Diverticulum on posterior pharyngeal wall |
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Role of the SLP in Esophageal Dysphasia
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- Understand how esophageal deficits might impact orophryngeal swallow functions/symptoms - Understand signs (e.g. during VFS) and symptoms (patient reports) that may indicate a need for further assessment by the GI physician - Understand esophageal treatments and their impact on oropharyngeal swallow functions - Reinforce esophageal treatments as appropriate - Possess a basic understanding on how the esophagus functions in the swallowing chain, basic symptoms of esophageal dysphagia, and how to assess esophageal dysphagia |
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How do breathing and swallowing interact? |
- They are closely related - Pathways "cross" in pharynx - Deficits in one can impact the other |
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Types of Artificial Airways |
- Endotracheal Tubes -> intubation/extubation - Tracheostomy Tubes -> cuffed/non-cuffed - Facial Masks -> CPAP and BPAP - Nasal Cannulas - Mechanial Ventilation |
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Endotracheal Tubes |
- Long plastic tube placed in the mouth - Runs through TVF - Connects to a ventilator - Temorary use to limit compliations - Long term use can cause intubation granulomas, hematoma, paralysis/weakness, pharyngeal ulceration/edema - Lung ventilator-associated pneumonia - If multiple reintubations, may require trach |
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Intubation and Swallowing
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- Swallow function may be factor in extubation - Ability to protect airway is critical - No clear leader in what evaluation to use - Sometimes eval is requested before extubation! - Duration of intubation is factor in post-extubation dysphagia (>48 hours) |
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Tracheostomy Tubes |
- Temporary or permanent - Stoma in trach - Curved plastic tube inserted into stoma and secured to neck - Often (not always) permits speech - Usually supports swallowing - Multiple sizes, larger is worse |
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Fenestration |
Holes in the trach that allow airflow to VF and out mouth and nose If the cuff is inflated, do not block trach! Client's exhaled air will have nowhere to go |
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Cuff is mainly for ensuring adequate ventilation Cuff is not a good barrier for prandial aspiration |
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What is the best trach for speech? |
- Downsized - Non-cuffed - Fenestrated tube |
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Complications of Trachs |
- Decreased smell from reduced airflow (esp. w/ inflated cuff) - Infection - Increased secretions, which increase risk of infection (v. COMMON) - RARE: tracheomalacia (causes tracheal collapse during cough, etc.), tracheoesophageal fistula (TEF) (hole between trachea and esophagus) - COMMON: Increased aspiration |
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Causes of Increased Aspiration in Trachs |
- Loss of subglottic pressure - Poor laryngeal elevation - Loss of airway sensitivity - Loss of laryngeal closure reflex |
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People say... "Trachs predispose ppl to aspiration because materials naturally want to flow to the area of least resistance" -- True? |
There is a higher incidence of aspiration in those with trachs, but may not be related to the trach itself |
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People say... "A trach tube will decrease laryngeal elevation" -- True? |
No - only one study Laryngeal elevation was not restricted Normal elevation is 2-3 cm, anterior movement most important |
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People say... "Less laryngeal tethering, more sensation, easier re-establishmentof airflow" -- True? |
Not always No relation between downsizing and dysphagia, but may be better for speech |
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REMEMBER: NEVER occlude a trach with an inflated cuff! |
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People say... "A closed system should facilitate safe swallow as it maintainsnormal pressure relationships, therefore, occluding the system should improve swallow safety; subglottic pressure generation helps in vocal foldclosure and in post-swallow clearing effort" -- True? |
Yes! General consensus is that valves: - Improve speech - Decrease upper-airway secretions - Restore smell - Improve ability to cough and clear secretions |
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Airway Evaluation - Physical Exams & Questions |
- Usually focuses on upper airway integrity and condition - Cuff status - Voicing - Trach tube/size and wearing plans - Suspected loss of cough - Time on/off ventilator and tolerance - Number and duration of intubations |
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Additional Care Items with Trachs |
- MEDICAL - Long length of stay - Secondary, chronic conditions - Reduced levels of strength - Nutrition issues - PATIENT-ORIENTED ISSUES - Anxiety and depression - Reduced compliance - Ability to perform trach care |
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Trach Weaning Protocol |
- Not a sig. aspiration risk (manages secretions) - Tolerating a minimum of 1 hour of speaking valve use with general supervision |
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Iatrogenic Dysphagia |
- Dysphagia secondary to a medical or surgical intervention - i.e., radiation, post-surgical, medication-induced |
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Post-Surgical Dysphagia |
- Head & neck procedures involving CN X, IX, sometimes XII) - Oral & laryngeal cancers - Thyroidectomy - Endarterectomy (removal/partial of an artery) - Antetior & posterior cervical fusion - Trans-hiatal esophagectomy - Skull base surgeries |
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Cervical Fusion |
- Deinnervation from irritation to the pharyngeal plexus (nerves that innervate pharynx and palate) - Post-op edema leading to weakness - Those with halos, worse outcome - Trach, worse outcome - But most recover after transient dysphagia/dysphonia! |
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Osteophytes
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- More common in older adults - Usually asymptomatic - >10 mm often associated with aspiration! - C3 and C6 prone to dysphagia due to mechanical obstruction |
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Esophagetcomy |
- Indication: Cancer - Aspiration due to fistula, VF immobility, tongue weakness, PES disorders - Smaller meals, anorexia - Gastric emptying-pyloric stenosis |
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Salient Characteristics of Cancer-Related Fatigue** |
- Feeling tired, weary, or exhausted even after sleep - Lacking energy to do daily activities - Trouble concentrating, thinking clearly, or remembering - Negative feelings, irritability, impatience, lack of motiviation - Lack of interest in daily activities |
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General Consequences of Malnutrition** |
- Increased susceptibility to infection - Reduced immune function - Respiratory failure - Poor wound healing - Skin breakdown - Death |
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Potential Side Effects from Chemo to Treat HNC** |
- Fatigue - N/V - Hair loss - Xerostomia - Loss of appetite - Reduced sense of taste - Weakned immune system - Diarrhea or constipation - Open sores in the mouth, poss. leading to infection |
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Potential Side Effects of RT Therapy to Treat HNC** |
- Redness and skin irritation in area treated - Permanent damage to salivary glands leading to xerostomia - Bone pain - NV - Fatigue - Mouth sores/sore throat - Dental probs - Painful swallowing - Loss of appetite |
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Common Interventions for Mucosal and Muscle Changes Resulting from RT Therapy for HNC** |
MUCOSAL CHANGES
- Salivary supplements - Water - Analgesics - Ice Chips - Mouthwash - Rx MUSCLE CHANGES - Cold (including ice chips) - Stretching exercises |
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Where are rings typically located? |
Near the esophageal junction |
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Differential Diagnosis of Esophagitis** |
- GERD - Infections - Truama (prolonged intubation) - Acute chemical ingestion - Drug-induced - Radiation - Skin conditions |
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Effects of Xerostomia |
- Dental caries - Poor initiation of swallow - Discomfort - Lack of taste - Poor oral hygeine - Fewer swallow responses |
