EVIDENCE BASED PRACTICE

EXPERT GUIDANCE:

Head and neck cancer dysphagia

In November 2004, speech and language therapists specialising EXPERT GUIDANCE: in head and neck cancer dysphagia met in Newcastle to seek DRIVERS FOR CHANGE consensus on their role. Jo Patterson reflects on the evidence KEY DOCUMENTS AND RESEARCH PROFESSIONAL CONSENSUS presented and the implications for future research.

ead and neck cancer and its treatment can have devastating effects on the ability to eat and drink. Rehabilitation of swallow disorders decreases the morbidity of aspiration and allows for better nutrition, better hydration and overall improvement in quality of life (Simental & Carrau, 2004). In 1996, Communicating Quality 2 stated that there were few speech and language therapists working in this field, training at undergraduate level was sparse and that clinicians tended to learn by experience. Over the past five years there have been some significant changes in practice. The number of dedicated speech and language therapy posts has increased, many pump primed by Macmillan Cancer Relief. Our role with this client group is now recognised by a number of key head and neck cancer documents (BAH-ONS Consensus document, 2000; NICE Head and Neck Cancer Improving Outcomes Guidance, 2004; RCSLT Guidelines, 2005; Scottish Intercollegiate Guidelines Head and Neck, in press). Treatment regimes have evolved. Surgeons have developed techniques to conserve certain key structures. Radiotherapy may be used in combination with chemotherapy (chemoradiotherapy). The consequence for function is under-represented in the literature. Our evidence based study day in Newcastle sought to address some of these changes and to seek consensus on the current role of speech and language therapy with this population. Three areas of clinical practice were appraised: pre-treatment assessment, instrumental assessment and intervention. A critical review of the literature was followed by case presentations and audience debate.

establish food preferences and routines for treatment planning and tailoring patient expectations (Appleton & Machin, 1995). clarify our role within the multidisciplinary team (Sullivan & Guilford, 1999). assess for dysphagia. This is often part of the presenting symptom and patients are frequently malnourished. Remedial nutritional and swallowing strategies may be introduced in preparation for treatment. Stenson et al. (2000) documented aspiration rates ranging from 14 per cent in oral cancer rising to 80 per cent in hypopharyngeal cancers. Advanced disease results in greater pharyngeal residue and poorer transit times (Pauloski et al., 2000). collect baseline information. The collection of pretreatment data is important for evaluating the effects of treatment. Dysphagia as a consequence of treatment should not be compared to a model of normal swallowing. teach exercises or manoeuvres in preparation for the effects of treatment (Kotz et al., 2004). There is no research to support this and further work is necessary.

Pre-treatment assessment is recommended. The evidence for our role is primarily expert opinion.
2. WHAT IS THE EVIDENCE FOR INSTRUMENTAL ASSESSMENT IN HEAD AND NECK CANCER DYSPHAGIA?
(speaker Jo Patterson, Sunderland Royal Infirmary) Head and neck cancer dysphagia can be complex, multi-factorial and subject to change due to disease progression or treatment effects. Assessment is necessary to understand the altered swallow physiology, to plan treatment, and for prognostic information and safety issues regarding eating and drinking. a. Which assessment should we use? A range of assessment tools is used in head and neck cancer research. The most commonly reported are videofluoroscopy and fibreoptic endoscopic evaluation of swallowing (FEES). In an American survey, speech and language therapists more commonly

1. WHAT IS THE EVIDENCE FOR PRETREATMENT ASSESSMENT?

(speaker Mary Jackson, Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary) Pre-treatment assessment is recommended by the guidelines mentioned. The evidence for our role is primarily expert opinion. The functions are to: offer reassurance, support, give information on potential swallowing difficulties and to engage the patient in the rehabilitation process (Logemann, 1993). Individual patients vary in how they prioritise treatment effects at this stage. Cure from cancer consistently ranks highly (List et al., 2000). Where there is a choice of treatments available, and survival rates are similar information on the functional consequences can be the deciding factor.

recommended videofluoroscopy as an adjunct to their clinical assessment, especially the less experienced clinicians. However, 51 per cent had access to videofluoroscopy compared to just 3 per cent FEES, which may have influenced their decision (MathersSchmidt & Kurlinski, 2003). In terms of cost, Aviv et al. (2001) found that the average price of a videofluoroscopy for a head and neck cancer patient was $451 compared to just $321 for a FEES. b. Assessment limitations In certain circumstances either videofluoroscopy or FEES will suffice. The clinician needs to be aware of the shortcomings of each test, as in some situations they are not inter-changeable. This can be demonstrated by comparing two nasopharyngeal cancer studies. Chang et al. (2003) used videofluoroscopy and Wu et al. (2000) used FEES to assess swallowing ability. Some outcomes were remarkably similar, for example pharyngeal stasis was observed in 80 per cent of patients in both studies. FEES identified more cases of post-swallow aspiration (77 per cent versus 4 per cent). This may reflect the time limits of radiation exposure during videofluoroscopy. Higher rates of aspiration during the swallow were seen via videofluoroscopy. This cannot be viewed via endoscopy due to white out. c. The role of assessment tools in therapy Instrumental tools may have a role in providing biofeedback during therapy. Logemann et al. (1992) compared videofluoroscopy used at intervals throughout therapy with clinical assessment alone. The videofluoroscopy group tended to start oral feeding later because aspiration was identified on x-ray. Conversely, this may lead to a more conservative approach as both groups were able to tolerate aspiration. On long-term follow-up, the videofluoroscopy group had better oropharyngeal efficiency scores, suggesting that therapy techniques were more focused. FEES has also been used in therapy (Denk & Kaider, 1997). A mixture of swallowing manoeuvres was taught via endoscopy and compared to a control group. Patients benefited from the biofeedback in the early stages of treatment. Further work is needed to identify which manoeuvres are best taught by this method.

3. WHAT IS THE EVIDENCE FOR HEAD AND NECK CANCER INTERVENTIONS?

(speakers Annette Kelly, the Royal National Throat Nose and Ear Hospital, London & Emer Scanlon, Western General Hospital, Edinburgh) A loss or reduction in function of the oral and pharyngeal stages of the swallow can respond to

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EVIDENCE BASED PRACTICE

compensatory procedures and therapy techniques. a. Swallowing manoeuvres Logemann et al. (1994a) and Logemann et al. (1997a) evaluated airway protection manoeuvres in post-radiotherapy and post-supraglottic laryngectomy patients respectively. In the irradiated patients, this technique reduced or completely resolved aspiration. The majority of the post-surgical patients (88 per cent) also benefited. Zuydam et al. (2000) reported on oropharyngeal patients, treated by surgery, some with adjuvant radiotherapy. The supraglottic swallow combined with chin tuck was successful for a third of the patients with large resections, and in all of those with a small resection. Patients also received range of motion exercises. These results are promising and support our intervention, but subject numbers are small (range 9 - 13).

Head and neck cancer dysphagia can be complex, multi-factorial and subject to change due to disease progression or treatment effects.
The duration and amplitude of tongue base to pharyngeal wall contact differs across swallowing manoeuvres (Lazarus et al., 2002a). All techniques (airway protection, effortful swallow, tongue hold manoeuvre, mendelsohn) improved contact and reduced residue in three laryngeal cancer patients. The mendelsohn achieved the longest contact but the effortful swallow had greater amplitude. There was little information on the reliability of measurements and again the subject numbers were small. b. Swallowing postures Logemann et al. (1994b) looked at the effects of different postures on 32 head and neck cancer patients who were known to aspirate. Patients with the same resection exhibited different swallow physiology, so different postures were employed. The breakdown in swallowing cannot be predicted by the nature of the treatment. Eighty one per cent of patients were able to swallow without aspiration following the introduction of a posture. It was ineffective for six patients (19 per cent). They had either extended laryngeal conservation surgery or resections involving more than one site. c. Swallowing exercises The use of range of motion exercises was reviewed in a pilot study without a control group (Logemann et al., 1997b). Improved swallow efficiency was observed in oral and oropharyngeal cancer patients. Shaker et al. (2002) randomised 27 dysphagic patients to compare a suprahyoid muscle strengthening exercise to a sham exercise.

Treatment groups had mixed aetiologies and 22 per cent had received radiotherapy for head and neck cancer. There was a significant increase in anterior laryngeal excursion and upper oesophageal opening. Aspiration resolved in all patients following six weeks of the exercise. A tongue holding manoeuvre for pharyngeal wall movement was assessed in a pilot study on 11 oral cancer patients (Fujiu & Logemann, 1996). There was no statistical difference on swallow transit times, but an increase in movement was observed. Further work is needed. d. Multidisciplinary interventions Only one paper was identified on prosthetic rehabilitation, on four patients (Logemann et al., 1989). Palatal prostheses were found to improve oral control. An increase in duration of tongue base to pharyngeal wall contact was also noted. Cricopharyngeal myotomy failed to improve swallowing in a multi-centre study of head and neck cancer patients (Jacobs et al., 1999). Lazarus et al. (2002b) reported a single case study where a laryngectomy had been performed due to protracted dysphagia post-chemoradiotherapy. Although successful in rectifying aspiration, the patient was unable to generate adequate tongue pressure to clear thicker textures. As with most of the literature relating to intervention, the patients perspective was not reported.

non-treatment control groups is problematic, given that our involvement has been recommended by guidelines. Small case series or single case studies are practical and useful. 3) National agreement There are no agreed national measures to enable multi-centre projects. In the future, Phase II of the Dataset for Head and Neck Oncology (DAHNO) may generate some basic information on outcomes. The NICE Improving Outcomes Guidance (2004) calls for more research on the timing and frequency of rehabilitation and which techniques are successful for specific impairments. With small numbers of clients, it is particularly important to consider a national or multi-centre approach. Jo Patterson is a speech and language therapist at Sunderland Royal Infirmary, e-mail [email protected]. The information in this article is based on a study day Evidenced Based Practice in Head & Neck Dysphagia Management at the Freeman Hospital Newcastle upon Tyne, 19 November 2004, organised by Paul Carding and Jo Patterson.

THE FUTURE
1) The evidence base The evidence base for speech and language therapy in head and neck cancer is limited and is predominantly supported by professional consensus. The NICE evidence review (2004) did not locate any studies conducted in the UK. Such studies do exist, although they are small in number. The NICE guidelines state that, although patients appeared to benefit from therapy, there were few details given on type of treatment. Much of the literature reviewed was retrospective with potential biases. Studies should be prospective and include details of therapy. 2) Research There are difficulties in conducting research in this area. Access to resources, funding, appropriate supervision and protected time can be problematic. There are a large number of variables to consider. Patient numbers are small, becoming more apparent when broken down to site and size of tumour and type of treatment. Small case series or single case studies may be the only appropriate design for certain groups but still provide clinically relevant material. Treatment side effects can be highly individual. Common problems such as pain, ulceration, dry mouth and taste changes are further considerations when measuring swallowing ability and response to therapy. Rate of attrition can be high for longitudinal studies due to the disease prognosis, alcohol addiction and social issues. Ethical approval for

A loss or reduction in function of the oral and pharyngeal stages of the swallow can respond to compensatory procedures and therapy techniques.
Acknowledgements
I would like to thank Kate Willson, Kate McFarlane, Helen Rust and Shannon Rees for case presentations at the study day, and Fiona Robinson and Paul Carding for chairing it.

References
Appleton, J. & Machin, J. (1995) Working with Oral Cancer. Bicester: Winslow Press Ltd. Aviv, J.E., Sataloff, R.T., Cohen, M. et al. (2001) Cost-effectiveness of two types of dysphagia care in head and neck cancer: A preliminary report, ENT Journal 80(8), pp. 553-556. British Association of Otohinolaryngologists - Head and Neck Surgeons (2001) Effective Head and Neck Cancer Management: Second Consensus Document. London: Royal College of Surgeons. Chang, Y.C., Chen, S.Y., Lui,,L.T. et al. (2003) Dysphagia in patients with nasopharyngeal cancer after radiation therapy: A videofluoroscopic swallowing study, Dysphagia 18, pp. 135-143. Denk, D.M. & Kaider, A. (1997) Videoendoscopic biofeedback: a simple method to improve the efficacy of swallowing rehabilitation of patients after head and neck surgery, Otorhinolaryngology 59, pp. 100-105. Fujiu, M. & Logemann, J.A. (1996) Effect of a tongue-holding manoeuvre on posterior pharyngeal wall movement during deglutition, American J Speech-Lang Path 5, pp. 23-30. Jacobs, J.R., Logemann, J.A., Pajak, T.F., Pauloski, B.R., Collins, S., Casino, R.R. & Schuller, D.E. (1999) Failure of cricopharyn-

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EVIDENCE BASED PRACTICE / REVIEWS

reviews
geal myotomy to improve dysphagia following head and neck cancer surgery, Arch Otolaryngol Head Neck Surg 125. Kotz, T., Costello, R., Li, Y. & Posner, M. (2004) Swallowing dysfunction after chemoradiation for advanced squamous cell carcinoma of the head and neck, Head & Neck pp. 365-372. Lazarus, C., Logemann, J.A., Song, C.W., Rademaker, A.W. & Kahrilas, P.J. (2002a) Effects of voluntary maneuvers on tongue base function for swallowing, Folia Phoniatr Logop 54, pp. 171-176. Lazarus, C., Logemann, J.A., Guoxiang, S., Kahrilas, P., Pelzer, H. & Kleinjan, K. (2002b) Does laryngectomy improve swallowing after chemoradiotherapy?, Arch Otolaryngol Head Neck Surg 128, pp. 54-57. List, M.A., Stracks, J., Colangelo, L. et al. (2000) How do head and neck cancer patients prioritize treatment outcomes before initiating treatment?, Journal Clinical Otolaryngology, 18, pp. 877-884. Logemann, J.A., Kahrilas, P.J., Hurst, P., Davis, J. & Krugler, C. (1989) Effects of intraoral prosthetics on swallowing in patients with oral cancer, Dysphagia 4, pp. 118-120. Logemann, J.A., Roa Pauloski, B., Rademaker, A., Cook, B., Graner, D., Milianti, F., Beery, Q., Stein, D., Bowman, J., Lazarus, C. et al. (1992) Impact of the diagnostic procedure on outcome measures of swallowing rehabilitation in head & neck cancer patients Dysphagia 7(4), pp. 179-86. Logemann, J.A. (1993) Evaluation and treatment of swallowing disorders. Pro-Ed. Logemann, J.A., Gibbons, P., Rademaker, A.W., Pauloski, B.R., Kahrilas, P.J., Bacon, M. et al. (1994a) Mechanisms of recovery of swallow after supraglottic laryngectomy, J Spch & Hear Res 37(5), pp. 965-74. Logemann, J.A., Rademaker, A.W., Pauloski, B.R. & Kahrilas, P.J. (1994b) Effects of postural change on aspiration in head and neck surgical patients, Otolaryngology - Head & Neck Surgery 110(2), pp. 222-7. Logemann, J.A., Pauloski, B.R., Rademaker, A.W. & Colangelo, L.A. (1997a) Super-supraglottic swallow in irradiated head & neck cancer patients, Head & Neck 19, pp. 535-540. Logemann, J.A., Pauloski, B.R., Rademaker, A.W. & Colangelo, L.A. (1997b) Speech and swallowing rehabilitation for head and neck cancer patients, Oncology 11(5), pp. 651-6. Mathers-Schmidt, B.A. & Kurlinski, M. (2003) Dysphagia Evaluation practices: Inconsistencies in Clinical Assessment and Instrumental Examination Decision-making, Dysphagia 18, pp. 114-125. National Institute for Clinical Excellence (2004) Improving Outcomes in Head and Neck Cancer. Available at: http://www.nice.org.uk (Accessed: 20 July 2005). Pauloski. B., Rademaker, A., Logemann, J., Stein, D., Beery, Q., Newman, L., Hanchett, C., Tusant, S. & MacCracken, E. (2000) Pretreatment swallow function in patients with head & neck cancer, Head & Neck pp. 474-482. Royal College of Speech & Language Therapists (2005) Clinical Guidelines. London: RCSLT, see www.rcslt.org Shaker, R., Easterling, C. et al. (2002) Rehabilitation of swallowing by exercise in tube-fed patients with pharyngeal dysphagia secondary to abnormal UES opening, Gastroenterology 122, pp. 1314-1321. Simental, A.A. & Carrau, R.L. (2004) Assessment of swallow function in patients with head and neck cancer, Current Oncology Reports 62, pp. 162-165. Stenson, K.M., MacCracken, E., List, M. et al. (2000) Swallowing function in patients with head and neck cancer prior to treatment, Archives Otolaryngol Head Neck Surg 126(3), pp. 371-375. Sullivan, P. & Guilford, A. (1999) Swallowing intervention in Oncology. Singular publishing group. Wu, C.H., Hsiao, T.Y., Ko, J.Y. & Hsu, M.M. (2000) Dysphagia after radiotherapy: endoscopic examination of swallowing in patients with nasopharyngeal cancer, Ann Otol Rhino Laryngol 109(3), pp. 320-325. Zuydam, A.C. et al. (2000) Swallowing rehabilitation after oro-pharyngeal resection for squamous cell carcinoma, Br J Oral & Maxillofacial Surgery 38, pp. 513-518.

BRIEF THERAPY
Focus On Solutions - A Health Professionals Guide Kidge Burns Whurr ISBN 1 86156 479 1 17.50

An excellent introduction
This book provides a practical, concise guide on how to incorporate a solutions based focus into our clinical work. It is written in a clear, readable style, giving specific examples and ideas to use with clients, and summarising each section in key points. It is like a working with tool, without being specifically focused on one client group. This book addresses most settings, that is acute, community, group work and family support. It provides the clinician with an insight into how to empower the client by enabling them to set and evaluate their own care aims and goals, using skills and abilities they themselves have identified as personal strengths. From the highly experienced therapist to the newly qualified professional, this professionals guide provides an excellent introduction to the concept of solution focused brief therapy. Elizabeth Ferguson, BA (Hons), MRCSLT is a specialist speech and language therapist in adult neurology with Wokingham PCT.

The script has interesting features to indicate movement, speed and intonation and is kept to a very simple level in terms of sentence length with generally familiar vocabulary. We tried the book with mainstream school children of 4 and 5 years of age with great success. Children with speech / language difficulties were able to follow the story and participated in discussion during and after the story. The class teacher was impressed by the amount of information the book encouraged from reluctant speakers. I would definitely use the book with children attending language groups in the clinic and would particularly recommend it for teachers / parents of children at the Foundation stage. Sue Ward is a speech and language therapist working in community clinics and mainstream schools for East Leeds PCT.

creating inclusive environments. I certainly think they have achieved this and it is a good resource for any professional team supporting schools to have. Sally Legerton, speech and language therapist, is Lead Clinician for Mainstream Schools, North Surrey PCT.

LANGUAGE DEVELOPMENT
Supporting Children with Speech and Language Cathy Allenby & Judith FearonWilson (Hull Learning Services) David Fulton Publishers ISBN 1-84312-225-1 10.00

Easy to dip into

This is a good, concise reference guide in a summarised form. It provides many helpful strategies to aid and develop a variety of skills. Example models for techniques are shown in a very accessible format. The bold print makes the book easy to dip into and locate specific details without problem. The general absence of technical language facilitates use by a range of providers. Mainstream classroom teachers would find the section on inclusion particularly helpful. The example of the speech and language individual education plan (IEP) would fit nicely into the completed scholastic IEP where required. Flowcharts, checklists and the explanations using childrens ideas were appreciated by the Support for Learning team within our school. The Support for Learning Team, Inverbrothock Primary School, Arbroath.

AUTISTIC SPECTRUM DISORDER

Supporting Children with Autistic Spectrum Disorder Colleen OConnell, Elizabeth Morling & Carole Stitt (Hull Learning Services) David Fulton Publishers ISBN 1-84312-219-7 10.00

Packed with strategies

This is an excellent resource for mainstream schools / nurseries, especially for teachers / learning support assistants who are new to supporting children with autistic spectrum disorder. It is packed with strategies which relate to curriculum topics as well as general classroom management and social skills. It gives specific examples on how to encourage independence to be used by support teaching staff. To help with supporting the family, it speaks about the wider emotional issues related to having a child with autistic spectrum disorder. The book is very succinct (49 pages). It is easy to locate information on a specific topic quickly. It aims to raise awareness and address issues involved in

CLINIC RESOURCE
Naughty Bus Jan & Jerry Oke Little Knowall Publishing ISBN 0 9547921 0 6 9.99

Encouraged reluctant speakers

This A4 sized paperback book details the antics of a toy red London bus and his toddler owner throughout the day. The pictures are photographic so are very clear and easily recognisable to young listeners. The story-line follows familiar routines such as eating breakfast, playing in the garden, splashing in the shower and going to bed at the end of a very busy day!

ASSESSMENT
Test of Morpheme Usage Neil Stevens Speechmark Publishing Ltd ISBN 0 86388 459 8 36.00+VAT

A helpful screening tool

The Test of Morpheme Usage provides therapists with a quick method of screening a clients use of 10 key morphemes (eg. possessives, past tense, auxiliaries). A range of interesting photographs and starter sentences are used to

Resources
Macmillan Cancer Relief, see www.macmillan.org.uk Scottish Intercollegiate Guidelines Network see www.sign.ac.uk

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