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.



  • 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.


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.

Normal Larynx

Laryngeal Edema


Dr Joanne Patterson (University of Liverpool)



Clinical Associate Professor, Otolaryngology (Head and Neck Surgery)


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.


  • Adaptation and Validation of the Dynamic Imaging Grade of Swallowing Toxicity for Flexible Endoscopic Evaluation of Swallowing: DIGEST-FEES. Journal of speech, language, and hearing research : JSLHR Starmer, H. M., Arrese, L., Langmore, S., Ma, Y., Murray, J., Patterson, J., Pisegna, J., Roe, J., Tabor-Gray, L., Hutcheson, K. 2021: 1-9


    Purpose While flexible endoscopic evaluation of swallowing (FEES) is a common clinical procedure used in the head and neck cancer (HNC) population, extant outcome measures for FEES such as bolus-level penetration-aspiration and residue scores are not well suited as global patient-level endpoint measures of dysphagia severity in cooperative group trials or clinical outcomes research. The Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) was initially developed and validated for use during videofluoroscopic evaluations as a way to grade safety, efficiency, and overall pharyngeal swallowing impairment. The purpose of this study was to adapt and validate DIGEST for use with FEES. Method A modified Delphi exercise was conducted for content validation, expert consensus, adaptation, and operationalization of DIGEST-FEES. Three blinded, expert raters then evaluated 100 de-identified post-HNC treatment FEES examinations. Intra- and interrater reliability were tested with quadratic weighted kappa. Criterion validity against the MD Anderson Dysphagia Inventory, Functional Oral Intake Scale, Secretion Severity Scale, and Yale Residue Rating Scale was assessed with Spearman correlation coefficients. Results Interrater reliability was almost perfect for overall DIGEST-FEES grade (kappaw = 0.83) and safety grade (kappaw = 0.86) and substantial for efficiency grade (kappaw = 0.74). Intrarater reliability was excellent for all raters (0.9-0.91). Overall DIGEST-FEES grade correlated with MD Anderson Dysphagia Inventory (r = -.43, p < .0001), Functional Oral Intake Scale (r = -.43, p < .0001), Secretion Severity Scale (r = .47, p < .0001), Yale Vallecular Residue (r = .73, p < .0001), and Yale Pyriform Sinus Residue (r = .65, p < .0001). Conclusion DIGEST-FEES is a valid and reliable scale to describe the severity of pharyngeal dysphagia in patients with HNC. Supplemental Material https://doi.org/10.23641/asha.14642787.

    View details for DOI 10.1044/2021_JSLHR-21-00014

    View details for PubMedID 34033498

  • The Stanford Multidisciplinary Swallowing Disorders Center. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association Nandwani, M., Dewan, K., Starmer, H., Kamal, A. N., Clarke, J. O. 2021

    View details for DOI 10.1016/j.cgh.2021.04.025

    View details for PubMedID 33887474

  • 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 Starmer, H. M., Drinnan, M., Bhabra, M., Watson, L., Patterson, J. 2021


    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. The Laryngoscope Dewan, K., Clarke, J. O., Kamal, A. N., Nandwani, M., Starmer, H. M. 2020


    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 Vergara, J., Starmer, H. M., Wallace, S., Bolton, L., Seedat, J., de Souza, C. M., Freitas, S. V., Skoretz, S. A. 2020


    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



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