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  • Esp in advanced carciinomas
  • Review article
    Education- all team members learn from each other’s perspectives
  • Mc nair found those involved in multi-d clinics were more likely to be enrolled in clinical research (65% versus 49%)
    Dwyer found no missed visits for multi-d clinic versus 2 missed visits per week in isolated clinic
    Kremp showed 50% reduction in missed visits
  • Dysphagia protocol included:
    Mendelsohn maneuver
    Tongue hold
    Tongue resistance
    Falsetto phonation
    Shaker exercises
    First four done 10 repetitions, five times daily
    Sustained Shaker three times daily; repetitive Shaker 30 times, five times daily
    No ROM for jaw
  • Adjusted for age, T-stage, site, follow up time, treatment, race and gender
    Global, emotional, and physical were statistically significantly different
    Conclusion is that pre tx exercises may potentially improve dysphagia related QOL
  • Dysphagia protocol included:
    Mendelsohn maneuver
    Tongue hold
    Tongue resistance
    Falsetto phonation
    Shaker exercises
    First four done 10 repetitions, five times daily
    Sustained Shaker three times daily; repetitive Shaker 30 times, five times daily
    No ROM for jaw
  • Fung - Patients with non-larynx head and neck cancers demonstrated increased supraglottic tension and thick secretions
    Meleca - Retrospectively reviewed a series of patients after rad/chemo rads for advanced laryngeal cancer and found the same findings with the addition of impaired vocal fold mobility, glottic incompetence, tissue irregularity, and asymmetry and attinuation of vibratory characteristics
  • Fung and Meleca also looked at patient perceived handicap and found that 27% of their patients reported significant handicap on the VHI. Interestingly higher levels of handicap were reported by young patients, and handicap increased as a function of time post-treatment
  • In 2006 Roh and colleagues looked at wide field versus site limited XRT for larynx ca (also included control group)
    Not surprisingly, the patients with wide field radiation had greatest disturbance of salivary function.
    Results similar to Logemann’s findings of xerostomia increasing perception of dysphagia vs actual dysfunction
  • Therapy will be individualized based upon patient complaints and deficits. We will briefly review some interventional strategies which may be helpful for patients after organ preservation.
  • Treatment group 9 patients underwent xrt, 3 laser surgery
    Average post-treatment time 31 months
    Average number of sessions 16
    Tx consisted of exercises and hygiene
  • Important to look at esophagus; many with pharyngoesophageal narrowing which is potentially treatable with dilatation
  • Treatment regimens differed. Two received RT. The remaining 12 received different chemotherapy agents.
    N = 7 <12 months post tx
    N = 7 >12 months post tx
    No statistically significant differences b/t groups
  • N = 140 normals
    Reduced BOT retraction also reported by Goguen
  • Investigated the relationship b/t swallowing impairments and oral intake/diet
  • Prospective cohort study
    F/u at 3, 6, 9, 12, 24 months post tx
    N = 59
    Primary tumor sites: oral cavity, oropharynx, hypopharynx, larynx
    Variables assessed included diet, gastrostomy tube removal, VFSS results, QOL
    Almost all return to full PO and have GT removed.
    9% had GT removed 1 – 2 years post tx, therefore important to have f/u.
    Median GT removal 21 weeks
  • 3/7 = 43%
    6/7 = 86%
    Gastrostomy tube: one from each group
    Still had deficits but resumed oral intake. A possible reason may be that the >12 month group had more therapy.
    Limitation = small N
    Organ sparing still has significant effect on swallowing. Preservation of structure does not always preserve function.
  • The number of patients with limited oral intake varied depending on the evaluation point. Before tx, 5/1% of all patients had oral intake of <50%. This percentage increased at 1 month post tx and then decreased over the first year. Prior to tx, 37.8% of patients had some restriction in their diet. This percentage increased at 1 month post tx and then fell to nearly pre-tx levels. By 1 year.
  • Relevant principles are goal selection, specificity and overload. The goal may be to increase strength, endurance or power, or some combination. Need to consider the types of motor units--slow twitch and fast twitch motor units. Slow twitch motor units are resistant to fatigue. Fast twitch motor units are of two types—fast fatiguable and fast resistant. Slow twitch units are recruited first, then fast resistant, then fast fatiguable as additional force is required. Exercises completed with low levels of resistance increase endurance. Exercises completed with high resistance increase strength. Exercises completed to the point of fatigue recruit slow and fast twitch motor units and improve strength and endurance.
  • The effects of strength training are specific to the trained behaviors. By matching the exercise as closely as possible to the desired movement outcome, specificity is maximized.
  • Increases in strength, endurance and power result from two physiological changes—hypertrophy (enlargement) of muscle fibers and recruitment of additional muscle units. These changes only occur when a muscle is taxed beyond its typical workload in terms of force or time requirements.
  • For example, Adachi and colleagues studied the effect of professional oral health care in 141 elederly residents of two nursing homes. They found that the incidence of fevers was lower in the group that received professional oral health care than in those who did not receive professional oral health care, ratio of fatal aspiration was significantly lower in the POHC group than he non-POHC group, and C. albicans was lower in the POHC group than in the non-POHC group.
    Similarly, Yoneyama and colleagues found that pneumonia (9% vs 21%, p<.01 in dentate patients; not signficant difference in edentate patients as there was a smaller number of patients in this group), febrile days and death from pneumonia was significantly decreased in those who had professional oral care.
  • Dilatation of CP, strictures, stenotic areas in esophagus; rupture of webs
  • Despite better fractionation schemes, more accurate focusing techniques, and prophylactic drugs, varying degrees of xerostomia reported by most patients. Signs of xerostomia are:
    Tongue depressor sticks to buccal mucosa
    “Lipstick” sign
    Dry, sticky, or erythematous oral mucosa
    Red patches on palate, tongue
    Decreased lingual papillae
    Little pooled salive in FOM
    Stringy, ropy, foamy saliva
    Educate patients about xerstomia and its effects.
  • SLPs can use xerostomia questionnaires—Xerostomia and QOL questionnaire in Henson et al, Oral Oncology, 2000 Saliva stimulants or sialagogues: sour tasting, sugarless candy and sugarless chewing gum stimulate saliva flow when functional saliva glands remain; saliva flow is increased only while candy or gum is in mouth
     
  • When saliva production cannot be stimulated…use pallitative measures
    Symptomatic management is required with substitutes, mouthwashes, etc
    Prevention and treatment of potential complications are necessary
    Use saliva substitutes, instruct in oral and dental hygiene, nutritional guidelines, fluoride applications
    Oral lubricants: Orajel, Vaseline 
    Cold air humidifer
    Criswell, et al, Laryngoscope, 2001: describe the FDA approved Vapotherm MT-3000 which provides hyperthermic, supersaturated water vapor via nasal cannula; n = 12; no additional benefit over standard, cool-air humidifer
     
     
  • Momm et al, Strahlentherapie und Onkologie,2005: crossover study comparing four saliva substitutes:Alidamed gel which contains aloe vera; Glandosane spray; rape oil; Saliva Medac spray containing mucin; n = 120; xerostomia improved with all compounds per patient report; best treatment was very individual; implication was that patients should try different compounds to identify what works best for them
     
  • Can also use dentrifices. Biotene and Oralbalance contain four salivary enzymes (lactoperoxidase, glucose oxidase, lysozyme, lactoferrin) to activate intra-oral bacterial systems (anti-microbial action to suppress microbial colonization and consequent inflammation)
    Biotene Dry Mouth Toothpaste
    Biotene Gentle Mouthwash
    Biotene Dry Mouth Gum
    Oral Balance Long-lasting Moisturizing Gel
    Biotene Dry Mouth Kit
    Regelink et al, Quintessence Int, 1998: 25 individuals with radiation induced xerostomia reported decreased sensation of oral dryness with use of Oral Balance gel
    Epstein et al, Oral Oncology, 1999: crossover study comparing Laclede products vs placebo; n = 19; greater improvement of xerostomia with Laclede; no oral antimicrobial action demonstrated b/c dwell time of products is limited
    Warde et al, 2000, Support Care cancer, 2000: Phase II study to evaluate Biotene/Oralbalance products; n = 28 pateints with post radiation xerstomia; 54% reported improvement in intraoral dryness, 46% reported improved ability to eat normally; 61% reported improved oral comfort
     Kam et al, Clin Oral Invest, 2005 and McMillan et al, Oral Oncology, 2006: intraoral device to allow slow release of Oralbalance gel
  • Dijkstra et al , Oral Oncol, 2004
    Prevalence 5% - 38% in head/neck cancer. Variation secondary to lack of uniform criteria, visual assessment, retrospective review.
    Implications for oral hygiene, biting, chewing, speaking, laughing, yawing, airway management.
    MIO = maximal incisal opening
    Establishes functional cut off for trismus in oncology patients
    Mention Therabite measuring tool (ruler) to standardize
  • Retrospective study; N = 27 patients with trismus secondary to head/neck SCCA and 8 with trismus secondary to other dx
    Treatment included active ROM, hold relax techniques, manual stretching, joint distraction, use of devices and tools. All patients received more than one type of treatment. Treatments were used at the discretion of the PT. 100% received AROM; 58% (22)received hold relax; 57% (21) received manual stretching; 21% (8) received joint distraction; 62% (23) received rubber plugs; 38% (14) received tong blades; 5% (2) received dynamic bite opener; 5% (2) received Therabite.
    Increase in mouth opening was significantly less in the head/neck SCCA group than in the other group. Each group received 6-7 treatments. Concluded that trismus is difficult to treat in head/neck cancer.
  • Controversy exists on topic of prophylactic feeding tube placement.
  • Application of neuromuscular electrical stimulation in head and neck patients is even more controversial.
  • Application of neuromuscular electrical stimulation in head and neck patients is even more controversial.
  • Transcript

    • 1. Treatment Protocols for Individuals Undergoing Organ Preservation Treatment Heather Starmer, M.S., CCC-SLP1 Donna C. Tippett, M.P.H., M.A., CCC-SLP1,2 Department of Otolaryngology—Head and Neck Surgery1 Department of Physical Medicine and Rehabilitation2 Johns Hopkins University
    • 2. Learner objectives • Explain treatment protocol from pre- to post-treatment • Describe therapeutic interventions that may be beneficial • Discuss current literature influencing clinical decision making
    • 3. Multidisciplinary assessment Pre-treatment SLP consultation Voice Swallowing Clinical controversies
    • 4. Multidisciplinary Assessment • Surgical oncology • Radiation oncology • Medical oncology • Speech-language pathology • Nursing • Social work • Dietary • Research coordinator • Clinical care coordinator
    • 5. Multidisciplinary Care • 2008 Practice guidelines consider multidisciplinary care as standard of care for head and neck cancer patients – NCCN (National Comprehensive Cancer Network) – ESMO (European Society of Medical Oncology) – AHNS (American Head and Neck Society)
    • 6. Multidisciplinary Care • Blair & Callender, 1994 – Collaboration and communication of multidisciplinary teams have had a profound effect on the treatment of head and neck cancer – “Essential for positive outcomes”
    • 7. Potential Benefits of Multidisciplinary Assessment • Westin & Stalfords, 2008 – Built in second opinion for treatment planning – Education – Increased consideration of ethics and QOL – Cost efficiency – Coordination of care – Improved patient outcomes
    • 8. Additional Benefits of Multidisciplinary Approach • Increased recruitment for research (McNair et al, 2008) • Fewer missed visits (Dwyer et al, 2008; Kremp et al, 2008)
    • 9. Tumor Board Conferences • Weekly • Confirm diagnosis and stage • Treatment planning • Referrals • Multidisciplinary
    • 10. Tumor Board Conferences • Head and neck surgeons • Medical oncologists • Radiation oncologists • Oral pathologists • Oncology nurses • Otolaryngology nurses • Speech-language pathologists • Dental prosthodontists • Nuclear medicine radiologists • Social workers • Dieticians
    • 11. Multidisciplinary assessment Pre-treatment SLP consultation Voice Swallowing Clinical controversies
    • 12. Roles of the Speech-Language Pathologist • Evaluation • Education • Exercises • Connections • Support • Swallowing • Voice • Speech • Oral Health • Research • Functional Outcomes
    • 13. Pre-treatment Evaluation • Clinical evaluation – Maximum jaw opening – Oral hygiene • Instrumental evaluation of swallowing – Videofluoroscopic assessment (VFSS) – Fiberoptic endoscopic evaluation (FEES) • Voice – Videostroboscopy – Acoustic/aerodynamic assessment • Quality of life • Patient and support analysis
    • 14. Pre-treatment Consultation • Education re: expected changes – Speech/voice – Swallowing – Oral health • Review VFSS/FEES – Diet modifications – Compensatory strategies • Pre-treatment swallowing exercises • Jaw ROM • Referrals
    • 15. Pre-treatment Information • Reduces anxiety • Improves post-treatment compliance • Involves the patient as a team member • Better post-tx speech targets Lazarus, 2005; Glaze, 2005
    • 16. Pre-treatment Swallowing Exercises • Lingual resistance • Straw resistance • Mendelsohn maneuver • Masako maneuver • Effortful swallow • “Sirening” technique • Jaw range of motion
    • 17. Pre-treatment Swallowing Exercises • Kulbersh et al, Laryngoscope, 2006 – Cross sectional analysis of QOL to determine efficacy of pre-tx intervention – Administered MDADI – N = 25 pre tx swallowing exercises – N = 12 post tx swallowing exercises
    • 18. Pre-treatment Swallowing Exercises • Kulbersh et al, 2006 – Adjusted Mean Scores on MDADI Domain Pre Tx Post Tx Global 74.4 32.9 Emotional 72.1 53.9 Functional 68.7 58.6 Physical 66.4 43.2
    • 19. Pre-treatment Swallowing Exercises • Carroll et al, Laryngoscope, 2008 – Retrospective analysis of outcomes of 18 patients • 9 patients initiated tx 2 weeks prior to XRT • 9 patients initiated tx after completion of XRT – Evaluation 3 months post-treatment
    • 20. Pre-treatment Swallowing Exercises • Carroll et al, 2008 – Significant benefit for pre-treatment group in: • Epiglottic inversion (p= .05) • Tongue base proximity to posterior pharyngeal wall (p= .025)
    • 21. Follow up Plan • Ongoing monitoring • Encourage oral intake as tolerated • Encourage daily exercise • Re-evaluate at the conclusion of tx
    • 22. Multidisciplinary assessment Pre-treatment SLP consultation Voice Swallowing Clinical controversies
    • 23. Common Voice Complaints • Reduced pitch variability • Reduced ability to sing • Reduced loudness • Reduced phrase length • Hoarse or breathy vocal quality • Vocal strain • Vocal fatigue
    • 24. Organ Preservation Approaches and Dysphonia • Videostroboscopic findings – Increased supraglottic tension – Pooling of thick secretions – Impaired mobility – Glottic incompetence – Irregularity of leading edge of vocal fold – Asymmetry and inadequate amplitude and mucosal wave Fung et al, Journal of Otolaryngology, 2001 Meleca et al, Laryngoscope, 2003
    • 25. Organ Preservation Approaches and Dysphonia Voice Handicap Index findings • 27% reported significant handicap • Self-perceived handicap greater in younger individuals • Handicap increased as a function of time post- treatment Fung et al, Journal of Otolaryngology, 2001 Meleca et al, Laryngoscope, 2003
    • 26. Organ Preservation Approaches and Dysphonia Acoustic/aerodynamic findings • Lower fundamental frequency for females • Elevated jitter and shimmer • Reduced MPT • Elevated subglottic pressure and glottal resistance Fung et al, Journal of Otolaryngology, 2001 Meleca et al, Laryngoscope, 2003
    • 27. Xerostomia and Voice • Roh et al, Journal of Clinical Oncology, 2005 – Wide field radiation had greatest impact on salivary flow (four fold difference) – Increased voice disturbance (elevated but not significant) – Increased abnormalities under videostroboscopy (supraglottic activity, dryness of vocal folds, stickiness of secretions) – Reduced voice related quality of life (moderate or greater impairment on VHI)
    • 28. Voice Therapy • Improve vocal hygiene • Improve glottic valving • Balance respiratory, phonatory, and resonant systems • Improve pliability and pitch variability • Reduce supraglottic constriction • Compensate
    • 29. Voice Intervention • vanGogh et al, Cancer, 2006 – Efficacy of voice therapy following treatment for laryngeal cancer – Findings: • Voice Handicap Index – Average improvement of 15 points post-treatment • Acoustic parameters – Improvement in NHR and jitter post-treatment – Subjective reduction in perception of vocal fry
    • 30. Hydration and Voice • Improving hydration may: – Reduce phonation threshold pressure – Reduce patient perceived vocal effort – Improve vocal quality Solomon & DiMattia, Journal of Voice, 2000 Verdolini et al, JSHR, 1994 Yiu and Chan, Journal of Voice, 2003
    • 31. Multidisciplinary assessment Pre-treatment SLP consultation Voice Swallowing Clinical controversies
    • 32. • Food gets stuck in the throat • Pills don’t go down well • Coughing or choking • Foods get stuck in the mouth • Mouth too dry for many foods Common Swallowing Complaints
    • 33. Characteristics of Dysphagia • Goguen et al, Otolaryngol Head Neck Surg, 2006 – Prospective cohort study – N = 23 s/p CRT for head/neck SCCA – Common deficits • Decreased epiglottic tilt • Decreased BOT retraction • Decreased laryngeal elevation • Impaired bolus propulsion • Laryngeal penetration/aspiration • 14/23 pharyngoesophageal narrowing
    • 34. Characteristics of Dysphagia • Dworkin et al, Dysphagia, 2006 – Retrospective study – Performed FEES in individuals with Stage III/IV laryngeal SCCA – Multiple decompensations • Excess oropharyngeal secretions • Premature spillage into vallecula • Retention in vallecula • Post cricoid residue • Laryngeal penetration/aspiration
    • 35. Characteristics of Dysphagia • Logemann et al, Head Neck, 2006 – Examined differences in swallowing across tumor sites and CRT protocols – VFSS pre- and 3 months post tx – N = 53 with Stage III/IV head/neck SCCA – Common deficits • Reduced BOT retraction • Reduced tongue strength • Delayed laryngeal vestibule closure
    • 36. Characteristics of Dysphagia • Pauloski et al, Head & Neck, 2006 – Prospective cohort study – VFSS pre- and post tx – N = 170 with head/neck SCCA – Identified multiple decompensations – Limitations in oral intake and diet post tx were significantly related to: • Reduced laryngeal elevation • Reduced CP opening • Rating of nonfunctional swallow on at least 1 bolus type
    • 37. Recovery • Goguen et al, 2006 Months % Soft or Regular Diet % GT Removed 3 17 27 6 53 63 9 70 80 12 80 81 24 97 90
    • 38. Recovery • Dworkin et al, Dysphagia, 2006 – N = 14 with Stage III/IV laryngeal SCCA – <12 months: 43% regular/near normal diet – >12 months: 86% regular/near normal diet Regular diet 3 Near normal diet 6 Puree 3 Gastrostomy tube 2
    • 39. Recovery • Pauloski et al, 2006 % with <50% oral intake % with non- normal diet Pre-tx 5.1 37.8 1 mos post 39.5 74.4 3 mos post 25.9 63.6 6 mos post 19.1 56.0 12 mos post 12.5 40.3
    • 40. Exercise Principles • Goal selection • Specificity of training • Overload/progression Clark, AJSLP, 2003
    • 41. Exercise Principles • Goal selection • Specificity of training • Overload/progression Clark, AJSLP , 2003
    • 42. Exercise Principles • Goal selection • Specificity of training • Overload/progression • Clark, AJSLP , 2003
    • 43. Therapy Targets • BOT retraction • Tongue strength • Laryngeal elevation Goguen et al, 2006 Logemann et al, 2006 Pauloski et al, 2006
    • 44. Oral Care as Treatment • Pneumonia, febrile days and death from pneumonia significantly decreased in patients with oral care than those without oral care Adachi et al, Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 2002 Yoneyama et al, J Am Geriatr Soc, 2002
    • 45. Medical/Surgical Tx for Dysphagia/Dysphonia • Dilatation –Surgical –Chemical • Cricopharyngeal myotomy/Botox • Vocal fold medialization by injection • Medialization thyroplasty
    • 46. Factors Affecting Recovery • Tumor site – Larynx, hypopharynx, BOT pharyngeal wall have more difficulty than tonsil, soft palate, oral cavity, nasal cavity, nasopharynx, UNK primary – Age – Baseline dysphagia Caudell et al, Int J Rad Onc Biol Phys, 2008
    • 47. Factors Affecting Recovery • Mucositis (Jones et al, 2006) • Early treatment (Lazarus et al, 1996; Pauloski et al, 2000; Rosenthal et al, 2006) • NPO intervals (Gillespie et al, 2004)
    • 48. Xerostomia Visual Inspection of the Mouth Photo courtesy of James Sciubba, DMD, PhD
    • 49. When residual gland function remains… • Can recommend: – Fresh, light acidic fruits – Slices of cold cucumber, tomato, melon, apple – Sour tasting, sugarless candy – Chewing gum – Vitamin C tablets per MD approval • Encourage routine and professional dental care
    • 50. When saliva production cannot be stimulated, recommend… • Frequent sips of water • Saline mouth rinse • Oral lubricants • Glycerin (may irritate oral mucosa) • Room humidifier – Criswell et al, Laryngoscope, 2001: Vapotherm MT-3000 • Changes in diet to avoid damage to fragile mucosa – Avoid dry, spicy foods – Avoid temperature extremes – Avoid alcohol, tobacco, caffeine, sugar containing products • Routine and professional dental care
    • 51. When saliva production cannot be stimulated… • Momm et al, Strahlentherapie und Onkologie, 2005 – Crossover study comparing four saliva substitutes – Best treatment was very individual – Recommend that patients try different agents to identify what works best for them
    • 52. When saliva production cannot be stimulated… • Biotene and Oralbalance – Contain salivary enzymes to suppress microbial colonization, inflammation – Decreased oral dryness (Regelink et al, Quintessence Int, 1998; Warde et al, Support Care Cancer, 2000) – No antimicrobial action; limited dwell time (Epstein et al, Oral Oncology,1999)
    • 53. Criteria for Trismus • Normal MIO 46+7mm Steelman et al, Mo Dent J, 1986 • MIO < 30 – 35mm Buchbinder et al, J Oral Maxillofac Surg, 1993; Dijkstra et al, J Oral Maxillofac Surg, 2006
    • 54. Treatment for Trismus • Buchbinder et al, J Oral Maxillofac Surg, 1993 – N = 21 s/p resection of oral SCCA and radiation tx <5 years Group Net increase at 6 wks Exercises 6.0mm (+/-1.8mm) Tongue blades 4.4mm (+/- 2.1mm) Therabite 13.6mm (+/- 1.6mm)
    • 55. Treatment for Trismus • Cohen et al, Arch Phys Med Rehab, 2005 – N = 7 s/p surgery for oropharyngeal SCCA MIO mm 12 - 48 wks post op Initial 30 (24 – 38) Final 40 (30 – 57) p < .01
    • 56. Treatment for Trismus • Dijkstra et al, Oral Oncology, 2007 Trismus related to head/neck SCCA Trismus not related to SCCA Mouth opening mean (SD) 19.3mm (7.4) 17.6mm (6.8) Increase in mouth opening mean (SD) 5.5mm (6.0) 17.1mm (9.0) p < .05
    • 57. Jaw ROM • Mandibular opening/lateralization • Pretend chewing • Three finger check
    • 58. Multidisciplinary assessment Pre-treatment SLP consultation Voice Swallowing Clinical controversies
    • 59. To tube or not to tube… • Body Mass Index (BMI) effects – Low BMI associated with: • Higher probability of recurrence • Lower overall survival McRackan et al, 2008
    • 60. To tube or not to tube… • Patients at greatest risk for weight loss during treatment – Nasopharynx or tongue base primary – Addition of chemotherapy to radiation – Hyperfractionated radiotherapy – Significant pre-treatment weight loss (>10% of weight 6 months prior to treatment) – Eating difficulties prior to treatment – Unpartnered male patients Beaver et al, 2001; Larsson et al, 2005; Konski et al, 2006; Piquet et al, 2002
    • 61. To tube or not to tube… • Positive effects of prophylactic tube feeding – Reduction in weight loss for elective, prophylactic tube feeds in contrast to therapeutic tube feeds or no tube (Chen et al, 2008) – Reduction in admissions for dehydration during treatment (Scolapio et al, 2001, Beaver et al, 2001) – Avoidance of treatment interruptions
    • 62. To tube or not to tube… • Mekhail et al, Cancer, 2001 – Those with NGFT • Less long term dysphagia • Shorter FT duration • Less need for dilatation – Stenting function – Motivate patients to swallow sooner
    • 63. To tube or not to tube… • Negative side effects of tube – Increased discomfort at tube site – Tube blockage – Tube migration or dislodgement – Peritonitis, perforation, tumor seeding (Rosenthal et al, 2006) – May lead to patient over-reliance • Scar and stricture formation (Caudell et al, 2008)
    • 64. How We Address It • Patient education • Patient encouragement • Regular follow up in high risk patients • Suggest prophylactic tube for patients in high risk groups
    • 65. To stim or not to stim… • Pro – Combine with other tx techniques • Effortful swallow – Use as a resistance exercise • Mendelsohn – May decrease fibrosis
    • 66. To stim or not to stim… • Con – Cannot stimulate deep muscles – Contraindicated in SCCA • Increasing metabolic activity