Heather Starmer Research Lab

Head & Neck Surgery

 

 

 

 

In addition to providing state of the art clinical care for communication and swallowing, our speech-language pathology team is engaged in clinical research to determine strategies to improve patient outcomes after a diagnosis of head and neck cancer. Our team recognizes the difficulties of going through cancer treatment and has particular interest in developing strategies to help patients make it through their treatment doing the therapies that will provide the best long-term outcomes. We collaborate closely with our surgeons, radiation oncologists, medical oncologists, and other team members to investigate how we can improve the patient experience of head and neck cancer care.

 

 

"Nothing would be more tiresome than eating and drinking if God had not made them a pleasure as well as a necessity.

— Voltaire

Our objective is to improve swallowing outcomes and patient satisfaction with swallowing after treatment for head and neck cancer.

Swallowing disorders are a common consequence of head and neck cancers and the treatments used to eradicate it.  Swallowing issues may be related to the removal of structures in the mouth or throat, scarring or fibrosis of the mouth and throat, or swelling of the mouth, throat, or neck.  Swallowing problems after head and neck cancer are cited as being the primary determinant of poor quality of life and may be associated with poor nutrition and development of aspiration pneumonia.  Given this reality, our work seeks to identify practical strategies to minimize dysphagia and it’s complications.

 

 

Harnessing the Power of Technology

Technology has the potential to influence healthcare in many different ways.  Approximately 10 years ago, Professor Starmer initiated work on a mobile application to support patients with head and neck cancer undergoing radiation therapy.  This application, called The Head and Neck Cancer Virtual Coach, provides patients with access to video workouts to perform to maintain the strength and mobility of their swallowing muscles, high quality content about how to manage side effects during treatment, recipes and videos of foods that are well tolerated during treatment, and reminders to perform important therapy tasks.  The impact of The Head and Neck Virtual Coach on patient outcomes and their experiences during treatment is currently under investigation at Stanford, Massachusetts Eye and Ear Infirmary, and the Fox Chase Cancer Center.

The Head and Neck Cancer Virtual Coach™ application screenshots.

Collaborators

 

  • Vibrent Health
  • Dr. Jeremy Richmon (Massachusetts Eye and Ear Infirmary)
  • Tessa Goldsmith (Massachusetts Eye and Ear Infirmary)
  • Barbara Ebersole (Fox Chase Cancer Center)

 

 

 

Effective Treatment Requires Precision Diagnostics

The ability to effectively manage swallowing disorders depends on diagnostic precision.  Swallowing is typically evaluated using either fluoroscopy, an x-ray movie, or endoscopy.  Both of these tools rely on an experienced clinician interpreting their images.  Without use of reliable, standard rating systems, these interpretations can be subjective and lead to poorer patient outcomes and inadequate communication between clinicians.  Further, research of advanced cancer treatments requires the ability to accurately assess the functional impact of the treatment.  To address these challenges, our lab strives to establish and validate measurement tools to be used in patients with swallowing disorders.  This work has resulted in the development of the DIGEST-FEES tool, which allows swallowing clinicians to reliably rate the safety and efficiency of an individual’s swallow using endoscopic assessment of swallowing.

Endoscopic Evaluation.

Endoscopic Evaluation of Swallowing.

Collaborator

Dr. Katherine Hutcheson (MD Anderson Cancer Center)

 

Lymphedema

Lymphedema can occur following surgery or radiotherapy for head and neck cancer.  Internal lymphedema can contribute to swallowing, voice and breathing difficulties.  Unlike external edema, there is no method currently available to measure internal edema.  In conjunction with researchers in the United Kingdom, our lab is working to develop a scale that can be used to quantify the severity of internal edema impacting the throat and voice box.

Normal Larynx

Laryngeal Edema

Collaborator

Dr Joanne Patterson (University of Liverpool)

 

 

Clinical Associate Professor, Otolaryngology (Head and Neck Surgery)

Bio

Heather Starmer is a Clinical Associate Professor and Director of the Head and Neck Cancer Speech and Swallowing Rehabilitation Center. Prior to joining the faculty at Stanford University, Heather served as the lead of the head and neck cancer rehabilitation program at Johns Hopkins University. Heather graduated from California State University at Long Beach in 1998 with a BA in Communicative Disorders. She earned her MA from the University of Pittsburgh in 2000. She completed her fellowship at the Veteran’s Administration Hospital in Pittsburgh with a focus in head and neck cancer and rehabilitation of swallowing disorders. Heather specializes in the rehabilitation of speech, voice, and swallowing in patients with head and neck cancer. She has particular interest in prevention of communication and swallowing disorders associated with radiation and chemotherapy. She has a strong interest in head and neck cancer survivorship and helping patients to accomplish their personal goals and to optimize their quality of life long term. She is a board certified specialist in swallowing disorders. Heather’s academic goals include improving communication and swallowing outcomes following a diagnosis of head and neck cancer through clinical research. She was a key member of a collaborative research group at Johns Hopkins resulting in multiple publications and presentations on strategies to minimize speech and swallowing difficulties. Recent advances in pain management during radiation therapy developed by this research collaborative have already shown great promise in protecting patients from potential swallowing difficulties during and after their cancer treatment. She works closely with colleagues in surgery, radiation oncology, and medical oncology to tackle the often difficult problems encountered by patients with head and neck cancer. She has particular interest in investigating the role of innovative surgical techniques such as Transoral Robotic Surgery (TORS) in minimizing long term functional deficits. Heather is involved in the education of future speech pathologists as well as residents and fellows in the Otolaryngology program. She regularly lectures on issues regarding rehabilitation of patients with head and neck cancer at multiple universities as well as at the national level. She is a member of multiple professional societies including the American Speech Language Hearing Association, the Dysphagia Research Society, and the American Head and Neck Society.

Publications

  • Assessment, Diagnosis, and Treatment of Dysphagia in Patients Infected With SARS-CoV-2: A Review of the Literature and International Guidelines. American journal of speech-language pathology Vergara, J., Skoretz, S. A., Brodsky, M. B., Miles, A., Langmore, S. E., Wallace, S., Seedat, J., Starmer, H. M., Bolton, L., Clave, P., Freitas, S. V., Bogaardt, H., Matsuo, K., de Souza, C. M., Mourao, L. F. 2020: 1–12

    Abstract

    Purpose Speech-language pathologists are playing a crucial role in the assessment and management of patients infected with severe acute respiratory syndrome coronavirus 2. Our goal was to synthesize peer-reviewed literature and association guidelines from around the world regarding dysphagia assessment and management for this specific population. Method A review of publications available in the PubMed database and official guidelines of international groups was performed on May 23, 2020. The information was synthesized and categorized into three content areas for swallowing: clinical evaluation, instrumental assessment, and rehabilitation. Results Five publications were identified in the PubMed database. Following title, abstract, and full-text review, only three publications met inclusion criteria: two reviews and one narrative report. Additionally, 19 international guidelines were reviewed. To assess swallowing, a modified clinical evaluation was recommended and only following a risk assessment. Instrumental assessments were often considered aerosol generating, especially transnasal procedures such as endoscopy and manometry. For this reason, many associations recommended that these examinations be performed only when essential and with appropriate personal protective equipment. Guidelines recommended that intervention should focus on compensatory strategies, including bolus modification, maneuvers/postural changes, and therapeutic exercises that can be conducted with physical distancing. Respiratory training devices were not recommended during rehabilitation. Conclusions International associations have provided extensive guidance regarding the level of risk related to the management of dysphagia in this population. To date, there are no scientific papers offering disease and/or recovery profiling for patients with dysphagia and coronavirus disease 2019. As a result, research in this area is urgently needed.

    View details for DOI 10.1044/2020_AJSLP-20-00163

    View details for PubMedID 32960646

  • Aspects of the assessment and management of pharyngoesophageal dysphagia. Annals of the New York Academy of Sciences Allen, J., Dewan, K., Herbert, H., Randall, D. R., Starmer, H., Stein, E. 2020

    Abstract

    Swallowing complaints are common and may have significant consequences for nutrition and pulmonary health. Etiology varies and different aspects of the deglutitive system may be affected. A thorough assessment from the oral cavity to the stomach will provide physiologic information that enables specific targeted management plans to be devised. Although the swallow trajectory bridges anatomic areas, there has previously been a tendency to compartmentalize assessment and treatment by arbitrary anatomic boundaries. It is now clear that this approach fails to appreciate the complexity of swallow mechanics and that systems (oral, pharyngeal, esophageal, and pulmonary) are intertwined and codependent. Swallowing specialists from different backgrounds and with complementary skill sets form a multidisciplinary team that can provide insight and address multiple areas of management. With the advent of new tools for instrumental evaluation, such as manometry, targeted rehabilitative strategies can be informed by physiology, increased in precision and breadth, and assessed quantitatively. Surgical approaches have evolved toward endoscopic techniques, and food technology is expanding options in dietary management. The multidisciplinary team is core to managing this varied and often neglected patient population. This review is for clinicians treating swallowing disorders and will explore the selected aspects of the assessment and management of pharyngoesophageal swallowing disorders.

    View details for DOI 10.1111/nyas.14456

    View details for PubMedID 32794195

  • Patient advocacy in head and neck cancer: realities, challenges and the role of the multi-disciplinary team. Clinical otolaryngology : official journal of ENT-UK ; official journal of Netherlands Society for Oto-Rhino-Laryngology & Cervico-Facial Surgery Dawson, C., Starmer, H., Nund, R., Coffey, M., Roe, J., Govender, R., Brady, G., Patterson, J. M., Topping, A., Nankivell, P., Parmar, S., Sharma, N., Pracy, P. 2020

    Abstract

    This paper explores the concept of advocacy in head and neck cancer. We define inherent challenges in the development and success of advocacy within this context, and offer ways to embed it within clinical practice. We outline what advocacy is, ways in which it may benefit people with head and neck cancer and the engagement required from health care professionals to facilitate advocacy to improve outcomes.

    View details for DOI 10.1111/coa.13508

    View details for PubMedID 31971339

  • Managing the Head and Neck Cancer Patient with Tracheostomy or Laryngectomy During the COVID-19 Pandemic. Head & neck Kligerman, M. P., Vukkadala, N., Tsang, R. K., Sunwoo, J. B., Holsinger, F. C., Chan, J. Y., Damrose, E. J., Kearney, A., Starmer, H. M. 2020

    View details for DOI 10.1002/hed.26171

    View details for PubMedID 32298035

  • Building an integrated multidisciplinary swallowing disorder clinic: considerations, challenges, and opportunities. Annals of the New York Academy of Sciences Starmer, H. M., Dewan, K., Kamal, A., Khan, A., Maclean, J., Randall, D. R. 2020

    Abstract

    Dysphagia is a complex condition with numerous causes, symptoms, and treatments. As such, patients with dysphagia commonly require a multidisciplinary approach to their evaluation and treatment. Integrated multidisciplinary clinics provide an optimal format for a collaborative approach to patient care. In this manuscript, we will discuss considerations for teams looking to build a multidisciplinary dysphagia clinic, including what professionals are typically involved, what patients benefit most from this approach, what tests are most appropriate for which symptoms, financial issues, and traversing interpersonal challenges.

    View details for DOI 10.1111/nyas.14435

    View details for PubMedID 32686095

 

 

For Donors

 

We would like to express our gratitude to the Toole Family Foundation, whose continuous generosity supports us in our battle against HPV related cancers.

 

 

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