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.
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.
- 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 of Swallowing.
Dr. Katherine Hutcheson (MD Anderson Cancer Center)
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.
Dr Joanne Patterson (University of Liverpool)
Development and reliability of the Revised Patterson Edema Scale.
Clinical otolaryngology : official journal of ENT-UK ; official journal of Netherlands Society for Oto-Rhino-Laryngology & Cervico-Facial Surgery
OBJECTIVE: The Patterson Edema scale was developed in 2007 to address the lack of a reliable, sensitive scale to measure laryngeal and pharyngeal edema in patients with head and neck cancer. The objective of this study was to revise the existing Patterson scale to improve its reliability and utility.DESIGN: Prospective investigation SETTING: Academic medical center PARTICIPANTS: Speech-Language Pathologists, Otolaryngologists, and Radiation Oncologists MAIN OUTCOME MEASURES: Ratings using the Revised Patterson Edema Scale METHODS: A consensus group reviewed existing literature regarding the performance of the original Patterson scale and revised the existing scale in regard to items to be included and descriptors for each severity level. The scale was then utilized by 18 speech language pathologists from the US and UK with >2 years-experience working with dysphagia and dysphonia with endoscopy. Each SLP rated a total of eight parameters (epiglottis, vallecula, pharyngoepiglottic folds, aryepiglottic folds, arytenoids, false vocal folds, true vocal folds, and pyriform sinuses) using the Revised Patterson Edema Scale. Feedback was solicited from raters regarding areas where clarity was lacking for further scale revision. Scale revisions were completed and additional ratings were completed by otolaryngologists, radiation oncologists, and less experienced SLP providers to establish reliability across disciplines. Quadratic weighted Kappa values were obtained to establish interrater reliability.RESULTS: Feedback received from raters included suggestions for clarification of how to rate unilateral edema, use of a standard task battery to visualize and rate structures consistently, and clarification of true vocal fold edema rating parameters. Overall interrater reliability was established using quadratic weighted Kappa with good agreement noted for the epiglottis, vallecula, arytenoids, andfalse vocal folds; moderate agreement noted for aryepiglottic folds, pharyngoepiglottic folds and pyriform sinuses; and fair agreement noted for true vocal folds.CONCLUSIONS: The Revised Patterson Edema Scale demonstrates moderate-substantial interrater reliability for most parameters across multiple disciplines and experience levels, with the exception of the true vocal folds where agreement was fair. We believe the Revised Patterson Edema Scale provides a reliable tool for clinicians and researchers to rate edema in the supraglottic larynx and pharynx following treatment for head and neck cancer.
View details for DOI 10.1111/coa.13727
View details for PubMedID 33529494
Patient Reported Outcomes and Objective Swallowing Assessments in a Multidisciplinary Dysphagia Clinic.
OBJECTIVES/HYPOTHESIS: Dysphagia encompasses a complex compilation of symptoms which often differ from findings of objective swallowing evaluations. The purpose of this investigation was to compare the results of subjective dysphagia measures to objective measures of swallowing in patients evaluated in a multidisciplinary dysphagia clinic.STUDY DESIGN: Prospective cohort study.METHODS: The study cohort included all patients evaluated in the multidisciplinary dysphagia clinic over 24months. Participants were evaluated by a multidisciplinary team including a laryngologist, gastroenterologist, and speech-language pathologist. Evaluation included a videofluoroscopic swallowing study (VFSS), fiberoptic endoscopic evaluation of swallowing (FEES), and transnasal esophagoscopy (TNE). Data collected included diet (FOIS), Eating Assessment Tool (EAT-10) score, Reflux symptom index (RSI) score, and the findings of the VFSS exam.RESULTS: A total of 75 patients were included in the analysis. The average EAT-10 score was 16.3±2.1, RSI was 21.4±0.6, and FOIS score was 6.0±1.33. VFSS revealed impairments in the oral phase in 40% of the cohort, pharyngeal in 59%, and esophageal in 49%. Abnormalities were noted in one phase for 32%, in 2 phases in 32%, and three phases in 18%. Patients with abnormal pharyngeal findings on VFSS had significantly higher EAT-10 scores (P = .04). Patients with abnormal oral findings on VFSS were noted to have significantly lower FOIS scores (P = .03).CONCLUSIONS: Data presented here demonstrate a relationship between patient reported symptoms and objective VFSS findings in a cohort of patients referred for multidisciplinary swallowing assessment suggesting such surveys are helpful screening tools but inadequate to fully characterize swallowing impairment.LEVEL OF EVIDENCE: 3 Laryngoscope, 2020.
View details for DOI 10.1002/lary.29194
View details for PubMedID 33103765
Swallowing and Communication Management of Tracheostomy and Laryngectomy in the Context of COVID-19: A Review.
JAMA otolaryngology-- head & neck surgery
Importance: The care of patients with a surgically modified airway, such as tracheostomy or laryngectomy, represents a challenge for speech-language pathologists (SLPs) in the context of the coronavirus disease 2019 (COVID-19) pandemic. The objective was to review available publications and practice guidelines on management of tracheostomy and laryngectomy in the context of COVID-19. This study performed a review and synthesis of information available in the PubMed database and from national SLP organizations across 6 countries.Observations: From the search, 22 publications on tracheostomy and 3 referring to laryngectomy were identified. After analysis of titles and abstracts followed by full-text review, 4 publications were identified as presenting guidelines for specific approaches to tracheostomy and were selected; all 3 publications on laryngectomy were selected. The main guidelines on tracheostomy described considerations during management (eg, cuff manipulation, suctioning, valve placement) owing to the increased risk of aerosol generation and transmission during swallowing and communication interventions in this population. Regarding laryngectomy, the guidelines focused on the care and protection of both the professional and the patient, offering recommendations on the management of adverse events and leakage of the tracheoesophageal prosthesis.Conclusions and Relevance: Frequent guideline updates for SLPs are necessary to inform best practice and ensure patient and health care worker protection and safety while providing high-quality care and rehabilitation.
View details for DOI 10.1001/jamaoto.2020.3720
View details for PubMedID 33057590
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
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
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
We would like to express our gratitude to the Toole Family Foundation, whose continuous generosity supports us in our battle against HPV related cancers.