When treating patients with head and neck cancer, there are many questions and pieces of the puzzle that need to be put together. You are always assessing where the cancer was, the type and amount of treatment received (surgery, CRT), prior and current swallowing status, etc.
Timing of therapy is critical for rehabilitation. Preferably, therapy can be initiated prior to cancer treatment so a baseline status and exercise program can be initiated with the patient. Most research has found that while it is impossible to completely avoid or reverse swallowing deficits following cancer treatment, that having the patient do something, including eating and drinking during therapy can increase outcomes.
There are a number of options available for treatment strategies when working with patients with head and neck cancer. Below is a discussion of a few of the strategies.
Dosing of exercises and patient compliance with prescribed protocol for dysphagia has been a hot topic of discussion in dysphagia management. Most exercises for swallowing have no prescribed dosing available.
Messing, et al 2017 examined swallowing rehabilitation during and after chemoradiation treatment (CRT). When completing exercises 2x/day for 7 days a week, patients demonstrated the greatest amount of progress 3 months post CRT. Progress was not seen long term. Exercises included:
- Mouth open wide stretch with the Therabite x10 per day
- Neck stretches
- Lip protrusion/retraction x10
- Retract tongue with a hold 3-5 seconds 10x
- Lingual elevation, depression, lateralization, protrusion, anterior/posterior motion x10 each direction
- Masako Maneuver x5
- Mendelsohn Maneuver x5
- Effortful Swallow with mist bottle or liquids x10
- Swallow frequently through the day
- Eat/drink by mouth (may use dietary modification/compensations)
- Use of spray mist/dry mouth products
- Stay hydrated
Langmore et al 2017 look at the efficacy of E-stim to enhance swallowing exercises in patients with head and neck cancer. This study found that in this population E-stim did not enhance swallowing exercises and, in fact, patients had worse swallowing. This study did state that “Since neither
compliant nor non-compliant patients benefitted from swallowing exercises, the proper dose and/or efficacy of swallowing exercises must also be questioned in this patient population.”
Carnaby et al 2012 developed a program for patients with head and neck cancer called Pharyngocise. Pharyngocise has had promising results in the head and neck cancer population.
Pharyngocise is a prophylactic exercise program for patient with head and neck cancer that is simultaneous with chemoradiation.
- Tongue Press
- Hard Swallow
- Jaw resistance/strengthening (TheraBite)
- The patient continues to eat by mouth, with diet modification as needed.
Exercises are completed in 10 reps/4 cycles of 10 min (45 min sessions), 2x/day during 6 weeks CRT. Exercises are completed 7 days a week.
Pharyngocise has had positive results in studies with:
Less deterioration in:
- dietary intake
- chemosensory function (smell and taste)
- nutritional status
- dysphagia-related complications
- Less structural deterioration in key muscles of swallowing including the genioglossus, hyoglossus and mylohyoid.
MD Anderson Boot Camp
Malandraki and Hutcheson 2018 describe 2 intensive therapies for dysphagia, one being a Boot Camp for patients with dysphagia due to head and neck cancer.
The MDAnderson Swallowing Boot Camp launched in 2012 with intervention typically before and during chemo/radiation therapy (CRT). Most patients had persistent or late onset moderate-severe dysphagia which was typically radiation induced or post-surgery.
There are 4 stages of Boot Camp
- Evaluation-including instrumental exam, PSS-HN, MDADI, Cranial Nerve and Oral Mech exam, physician exam along with any other evaluations needed including peak flow cough, nasopharyngoscopy, etc.
- Consensus and Planning-Reviewed by the team using a checklist ensure the patient qualified for boot camp.
- Optimization Phase (Pre-Boot Camp) When any surgical intervention was completed including, but not limited to, esophageal dilatation, vocal fold medialization, manual therapy or dental rehab.
- Functional Phase (Boot Camp) Clinician-directed, intensive functional therapy with daily sessions over 2-3 weeks. Therapy sessions at 100+ swallows per session under progressive conditions. Device (sEMG) and bolus (MDTP) driven options available.
Boot Camp optimizes the functional status of a patient to hel pthem to adapt to a new normal with swallowing.
When working with patients with head and neck cancer, it is always important to try to assess these patients prior to any treatment. If an instrumental assessment can be utilized, you will be able to create a solid baseline for your patient.
Exercises can be initiated prior to any treatment with therapy, exercises completed at home and therapy sessions throughout treatment and exercises continued after treatment. While more studies need to be completed, it is often found that patients doing something or patients continuing to eat before, throughout and after CRT may have a better quality of life.
Daele et al “Beginning a swallowing therapy program within one year of completion of radiation therapy demonstrates more consistent improvement in quality of life and diet performance compared to later time periods.”
Want to read more about the research behind Pharyngocise?
Crary, M. A., & Carnaby, G. D. (2014). Adoption into clinical practice of two therapies to manage swallowing disorders: exercise based swallowing rehabilitation and electrical stimulation. Current opinion in otolaryngology & head and neck surgery, 22(3), 172.
Wall, L. R., Ward, E. C., Cartmill, B., Hill, A. J., & Porceddu, S. V. (2017). Adherence to a prophylactic swallowing therapy program during (chemo) radiotherapy: impact of service-delivery model and patient factors. Dysphagia, 32(2), 279-292.
Pryor, J. C. (2018). Beyond “Pharyngocise” for Patients With Head and Neck Cancer: Does One Size Fit All?. JAMA Otolaryngology–Head & Neck Surgery, 144(6), 488-489.
Carnaby-Mann, G., Crary, M. A., Schmalfuss, I., & Amdur, R. (2012). “Pharyngocise”: randomized controlled trial of preventative exercises to maintain muscle structure and swallowing function during head-and-neck chemoradiotherapy. International Journal of Radiation Oncology* Biology* Physics, 83(1), 210-219.
Langmore, S. E., McCulloch, T. M., Krisciunas, G. P., Lazarus, C. L., Van Daele, D. J., Pauloski, B. R., … & Doros, G. (2016). Efficacy of electrical stimulation and exercise for dysphagia in patients with head and neck cancer: a randomized clinical trial. Head & neck, 38(S1), E1221-E1231.
Krisciunas, G. P., Castellano, K., McCulloch, T. M., Lazarus, C. L., Pauloski, B. R., Meyer, T. K., … & Langmore, S. E. (2017). Impact of compliance on dysphagia rehabilitation in head and neck cancer patients: results from a multi-center clinical trial. Dysphagia, 32(2), 327-336.
Messing, B. P., Ward, E. C., Lazarus, C. L., Kim, M., Zhou, X., Silinonte, J., … & Califano, J. (2017). Prophylactic swallow therapy for patients with head and neck cancer undergoing chemoradiotherapy: a randomized trial. Dysphagia, 32(4), 487-500.
Van Daele, D. J., Langmore, S. E., Krisciunas, G. P., Lazarus, C. L., Pauloski, B. R., McCulloch, T. M., … & Mott, S. L. (2019). The impact of time after radiation treatment on dysphagia in patients with head and neck cancer enrolled in a swallowing therapy program. Head & neck, 41(3), 606-614.
Malandraki, G. A., & Hutcheson, K. A. (2018). Intensive therapies for dysphagia: implementation of the intensive dysphagia rehabilitation and the MD Anderson Swallowing Boot Camp Approaches. Perspectives of the ASHA Special Interest Groups, 3(13), 133-145.