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)

Publications

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 

Abstract

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

 

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)

Publications

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

Abstract

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

 

 

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

  • The American Broncho-Esophagological Association Position Statement on Swallowing Fluoroscopy. The Laryngoscope Dhar, S. I., Nativ-Zeltzer, N., Starmer, H., Morimoto, L. N., Evangelista, L., O'Rourke, A., Fritz, M., Rameau, A., Randall, D., Cates, D., Allen, J., Postma, G., Kuhn, M., Belafsky, P. 2022

    Abstract

    OBJECTIVES: To develop an expert consensus statement on the clinical use of swallowing fluoroscopy in adults that reduces practice variation and identifies opportunities for quality improvement in the care of patients suffering from swallowing impairment.METHODOLOGY: A search strategist reviewed data sources (PubMed, Embase, Cochrane, Web of Science, Scopus) to use as evidence for an expert development group to compose statements focusing on areas of controversy regarding swallowing fluoroscopy. Candidate statements underwent two iterations of a modified Delphi protocol to reach consensus.RESULTS: A total of 2184 publications were identified for title and abstract review with 211 publications meeting the criteria for full text review. Of these, 148 articles were included for review. An additional 116 publications were also included after reviewing the references of the full text publications from the initial search. These 264 references guided the authors to develop 41 candidate statements in various categories. Forty statements encompassing patient selection, fluoroscopic study choice, radiation safety, clinical team dynamics, training requirements, videofluoroscopic swallow study and esophagram techniques, and interpretation of swallowing fluoroscopy met criteria for consensus. One statement on esophagram technique reached near-consensus.CONCLUSIONS: These 40 statements pertaining to the comprehensive use of swallowing fluoroscopy in adults can guide the development of best practices, improve quality and safety of care, and influence policy in both the outpatient and inpatient settings. The lack of consensus on some aspects of esophagram technique likely reflects gaps in knowledge and clinical practice variation and should be a target for future research. Laryngoscope, 2022.

    View details for DOI 10.1002/lary.30177

    View details for PubMedID 35543231

  • Timing of postoperative oral feeding after head and neck mucosal free flap reconstruction. Laryngoscope investigative otolaryngology Stramiello, J., Nuyen, B., Saraswathula, A., Blumenfeld, L., Divi, V., Rosenthal, E., Orosco, R., Starmer, H. M. 2021; 6 (5): 1031-1036

    Abstract

    Fistula remains a common complication of upper aerodigestive tract reconstruction. Optimal timing of oral feeding is unknown and the impact of early feeding on swallow function and fistula rates remains controversial. The purpose of this study is to better understand the effects of "early feeding" on fistula rate and swallow in patients with free flap reconstruction of upper aerodigestive tract defects.Retrospective cohort study. One hundred and four patients undergoing free flap reconstruction of mucosalized head and neck defects. Two groups, early feeding (oral intake on or before postoperative day 5) and late-feeding (oral intake after postoperative day 5). Primary outcome was incidence of salivary fistula. Secondary outcomes included Functional Oral Intake Scale scores.Fistula rate was 16.5% in late-feeding group and 0% in early-feeding group (P = .035). Patients who were fed early had an association with progression to a full oral diet by 30 days (P = .027).This cohort analysis suggests that in properly selected patients with free flap reconstruction for mucosal defects, early feeding may not increase risk of salivary fistula and may improve swallow functional outcomes earlier. Level of Evidence: 3.

    View details for DOI 10.1002/lio2.655

    View details for PubMedID 34667846

    View details for PubMedCentralID PMC8513441

  • Timing of postoperative oral feeding after head and neck mucosal free flap reconstruction LARYNGOSCOPE INVESTIGATIVE OTOLARYNGOLOGY Stramiello, J., Nuyen, B., Saraswathula, A., Blumenfeld, L., Divi, V., Rosenthal, E., Orosco, R., Starmer, H. M. 2021

    View details for DOI 10.1002/lio2.655

    View details for Web of Science ID 000695542500001

  • 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

    Abstract

    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

 

 

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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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