Strategic Therapy Planning for Swallowing Disorders After by itlpw9937



      Strategic Therapy Planning for
        Swallowing Disorders After
    Treatment for Head & Neck Cancer
Session Number: 1981
Day/Time: Friday, November 20, 2009 9:30AM-11:30AM
Room: Ballroom C
Location: Ernest N. Morial Convention Center
                             Mary J. Bacon, MA CCC-SLP, BRS-S
                                Rush University Medical Center
                                         Chicago, IL

Purpose of this session

        Highlight effects of treatments for head and neck cancer on swallowing function
        Illustrate ways in which management decisions are based on objective data

Patient MG

        Base of tongue cancer diagnosed 20 years prior and treated with laser intraoral resection
        and neck dissection followed by radiation therapy
        Gradual worsening of dysphagia over the years
        Previous MBSs in 2002, 2004, 2007

Effect of his cancer treatment

        This patient’s swallowing was likely affected by the initial BOT resection
        (Hirano, M. et al. (1992). Dysphagia following various degrees of surgical resection for
         oral cancer. Annals of Otol. Rhinol. and Laryngology,101(2 pt. 1),138-141.)
        The gradual worsening of his dysphagia over the years is probably due to tissue fibrosis
        due to the radiation therapy he received
        (Pauloski, B., Rademaker, A., Logemann, J., & Colangelo, L. (1998). Speech and
        swallowing in irradiated and nonirradiated postsurgical oral cancer patients.
        Otolaryngology and Head and Neck Surgery,118(5), 616-624.)

Previous MBS (2007)

        Recommendation of NPO
             Placement of G-tube 1 year before
                • Pt continues to drink water and coffee

                 Pt had several pneumonias before G-tube placement; has had one pneumonia
                 since G-tube placement

Current question

        Can I take more material by mouth?
                Can I just go ahead and swallow more consistencies/larger boluses?
                Can I broaden what I eat and drink if I use compensations?

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Decisions based on objective data

        Modified barium swallow (MBS) was used to arrive at decisions regarding dysphagia
        management for this patient.
        Pt’s goal of more material by mouth was kept in mind

Oral transit

        Pt had mild oral transit difficulties

Initial clip - baseline

        Calibrated bolus of liquid
        Pt’s usual habit (drink from cup)
        Calibrated bolus of puree

        Masticated material deferred

Initial observations

        Observe this clip for:
              Ability to keep glottis closed
              Inability to close vestibule
              Inability to clear pharynx
              Aspiration from pyriform sinuses post-swallow
        Observe for
              Hyolaryngeal elevation
              BOT to pharyngeal wall approximation

Initial clip - baseline

Impairment profile for this moderately severe dysphagia

        Reduced tongue base to pharyngeal wall approximation/pharyngeal constriction
        Reduced hyolaryngeal elevation

                 Resulting in reduced vestibule closure
                 Reduced pharyngeal shortening likely
                 Reduced pressure on bolus likely
                 ? Reduced opening of the p-e segment
                        Leaving material in the pharynx and vestibule
                        To be aspirated after swallows
                        Also inefficient (need for multiple swallows per bolus)

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        A. Stop the exam and recommend strict NPO
        B. Stop the exam and recommend pt continue with small sips of water and coffee
        C. Continue the exam
        Which compensations should be tried?
               Jot down three that you might use

Compensation trials

        Would a consistency between liquid and puree allow the pt to perform more of the
        spontaneously occurring compensations before he loses material to the airway, yet reduce
        the amount of pharyngeal residue remaining?
               (Kuhlemeier,K., Palmer, J.,& Rosenberg, D,.(2001). Effect of liquid bolus
               consistency and delivery method on aspiration and pharyngeal retention in
               dysphagia patients. Dysphagia,16(2), 119-22.)

Clip of thickened liquid swallow

Compensation trials

        He is able to close his glottis while he is swallowing, so would a super-supraglottic
        swallow close his vestibule more adequately and allow him to clear and re-swallow any
        remaining residue?
        (Martin, B., Logemann, J., Shaker, R., & Dodds, W. (1993). Normal laryngeal valving
        patterns during three breath-hold maneuvers: A pilot study. Dysphagia, 8(1),11-20.)

Clip of super-supraglottic swallow

Compensation trials

        Would a chin tuck narrow the pharynx and thus promote improved pharyngeal clearance?
        (Welch, M., Logemann, J., Rademaker, A. & Kahrilis, P. (1993). Changes in pharyngeal
        dimensions effected by chin tuck. Archives of Phys Med and Rehab, 74(2),178-181.)

Clip of chin tuck

Compensation trials

        Would a head turn added to the chin tuck promote a little more UES opening and/or add
        to the pressure on the bolus/pharyngeal clearance?
        (Logemann, J., Kahrilis, p., Kobara, M.,& Vakil, N. (1989). The benefit of head rotation
        on pharyngoesophageal dysphagia. Archives of Phys. Med. and Rehab., 70(10),767-771.)

Clip of head turn (with chin tuck)

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Anterior/Posterior view

Will aspiration be eliminated by any combination of compensations?
   A. Yes
   B. No

Will aspiration be reduced by any combination of compensations?
   A. Yes
   B. No

What would you recommend as the best combination of compensations?
      Head turn to the right with chin tuck and multiple swallows
      Liquids require ~ 3 swallows per sip
      Purees require ~6 swallows per tsp

                          Swallowing will be tedious!

Audience review
      Your list of compensations to try may have been similar, or you may have had other ideas
      for this patient.

What about swallowing therapy?
(Patient had a course of swallow therapy in 2002)

    A. Yes
    B. No

Answer to patient’s question

        Can I take more by mouth?

                          Yes, if willing to follow the recommendations.

Did we help this man?

        He cannot eat a full diet by mouth – far from it
        By aggressive use of trials, a set of compensations was found that will allow this patient
              Eliminate some aspiration for liquids he already drinks
              Increase the amount of and types of materials he can take by mouth

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                         Joy Gaziano, MS, CCC-SLP, BRS-S
                  USF Center for Esophageal and Swallowing Disorders
                              University of South Florida
                                    Tampa, Florida

Background History

        72 year old male with multiple treatment modalities for SCCA.
        2000-SCCA BOT tx with XRT and right RND.
        2003-Recurrence-> left mandibulectomy.
        2004-Recurrence->left ear excision and XRT. Dysphagia onset.
        2007-Recurrence->partial (L) glossectomy and FOM resection.

Swallowing History

        Tolerating a liquid diet until 3 months ago with gradual worsening function.
        Rapid worsening over several days… “unable to swallow anything.” Weight loss,
        weakness, malaise. Coughing on every meal attempt. Nocturnal cough.
        Swallowing therapy March 2005, June 2006, February 2007.
        PEG 2007 after esophageal perforation during dilation for stricture.

Clinical Swallow Assessment

        Right 1/3 tongue absent and tethered on left. Globally reduced strength and ROM.
        Edentulous; pooled oral secretions
        Inadequate labial seal with anterior leakage and pooling in anterior and lateral sulci
        Delay in swallow response using neck palpation.
        Wet voice quality after liquid swallow.
        Speech dysarthric with predictable articulatory breakdown.

Initial MBS

Initial Impressions

        Severe oral phase deficits
        Reduced BOT retraction
        Pharyngeal retention
        Penetration and aspiration
        Anything else?

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Clinical Decision Making

What do you do next?
A. Stop study/recommend NPO. Patient is unsafe with documented aspiration of unknown
etiology. Suggest neuro consult.
B. Move to nectar thick liquids to assess impact on aspiration risk.
C. Take AP view and assess esophagus.
D. Try postural/compensatory strategies.

MBS continued…

Treatment Plan

        Serial dilations by gastroenterologist
        PEG tube for nutrition, weight gain and energy
        Supplement with small volumes thin/thick liquids for pleasure and therapy
        Aggressive exercise program including tongue and BOT ROM, effortful swallow,
        falsetto, supraglottic swallow.

Treatment Plan Continued
      Oral care
      Refit dentures
      Suck/swallow for saliva management
      Physical therapy for improved neck ROM
      Right oral cavity placement with head tilt right
      Cold liquids to enhance sensory response
      Liquid wash /liquid push with puree/soft solids
      Pills crushed or liquid

Post Tx MBS

Findings and Functional Status

        Improved but persistently impaired swallow after 3 months of serial dilations and 2
        months home exercise program.
        Esophageal stricture resolved.
        Consumes 4 liquid supplements and 16 oz. H20, and small amounts thin puree daily.
        1 can via PEG.
        Better secretion management, dentures fit, weight and pulmonary status stable.


        PEG tube “fell out” at home in May 2009 with no need to replace.
        Suffered a L CVA August 2009 with right hemiparesis, aphasia and no change on
        Displays amazing determination and resilience in efforts to maximize his QOL.

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                            Mario A. Landera, MA, CCC-SLP
                        University of Miami Miller School of Medicine
                                         Miami, FL

Case Presentation: GJ

        80 yo male s/p left partial glossectomy with left complete neck dissection and
        postoperative radiation therapy due to SCC of tongue treated in 1987.
        Received speech and swallowing therapy afterwards for approximately 6-8 months.
        Tolerating a near regular diet with liquids until…..

        ….May 2008
                   Tickle in his throat
                   Frequently clearing his throat
                   Coughing when swallowing
                   Decreased appetite
                   Gradual loss of weight
                   Night sweats
                   Speech getting worse

        July 2008:
               Hospitalized for aspiration pneumonia and empyema
               MBS performed at outside hospital
                      Significant aspiration
                      Absence of epiglottis
                      Narrowing of the esophagus
               PEG tube placed; no swallowing therapy
               PET/CT: findings consistent with H&N treatments; otherwise unremarkable

        October 2008
              Second opinion at the University of Miami Sylvester Comprehensive Cancer

        Oral Mechanism Exam
              Labial structures: Strength and ROM are WNL with adequate closure
              Lingual structures: Minimal-moderate strength and ROM during protrusion and
              right lateralization with minimal strength and ROM during left lateralization
              Hard palate: WNL
              Soft palate: minimally reduced velopharyngeal excursion; asymmetric
              Laryngeal excursion: Significantly reduced

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Do we have enough information to make recommendations?

    A.   Continue with clinical swallow exam/food trials
    B.   Perform a FEES
    C.   Perform an MBS
    D.   Start him on some swallowing exercises
    E.   He has no epiglottis silly. He has no chance of eating again.

MBS October 2008 –Video Clip
     What do you see?

   A. Start him on an oral diet with _______ consistency
   B. NPO; continue with PEG
   C. Begin swallowing therapy
   D. Have him fly to Chicago to see Dr. Logemann

   A. Excellent
   B. Good
   C. Fair/Guarded
   D. Poor

Likely Cause of his Dysphagia?

     NPO; continue with PEG tube
     Begin behavioral swallowing therapy
            What exercises?

Swallowing Exercises
      Range of motion tongue exercises (Logemann et al., 1997)
      Resistance exercises (Jordan, 1979)
      Mendelsohn maneuver (Ding et al., 2002; Dodds et al., 1988; Boden et al., 2006)
      Masako maneuver (Lazarus, Logemann, Song, Rademaker, & Kahrilas, 2002; Fujiu &
      Logemann, 1996)
      Effortful swallow (Bulow et al., 2001; Hind et al., 2001; Huckabee et al., 2005)
      Thermal-tactile stimulation (Sciortino et al., 2003; Rosenbek et al., 1998; Lazarra et al.,

Swallowing Progress
      4 sessions of swallowing therapy
      GJ practiced exercises 5/5/5
      Demonstrating improvements with lingual motion and laryngeal elevation

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MBS November 2008-Video Clip
     What do you see?

     Gradually begin oral diet with nectar and honey consistencies with head turn to the right
     Decrease enteral nutritional feedings through PEG tube
     Continue swallowing therapy

       6 more sessions of swallowing therapy
       Patient still practicing exercises 5/5/5
       Taking ~40% of nutrition PO, consisting of thickened liquids with head turn to the right

MBS February 2009-Video Clip
     What do you see?

     Advance oral diet to mechanical soft with thin liquids while using head turn to right
     Use liquid wash after thicker consistencies
     Continue increasing oral intake while decreasing enteral nutrition

Do we stop his exercise regimen?
   A. Yes, he is now able to swallow so he does not need to waste his time with this
   B. No, continue 5 times a day, 5 times each, 5 days of the week
   C. No, but taper the frequency

Swallowing Rehab Update
      GJ is now taking ~80% of his nutrition PO, consisting of a near-regular diet
      Still uses a head turn to his right and liquid wash in between thicker consistencies
      Remaining ~20% of his nutrition through PEG tube
      Practicing his exercises twice a day
      Improved QOL

Take Home Message
      Always apply postural maneuvers/ strategies during your exam to see if you can improve
      bolus flow and/or decrease risk of aspiration
      Side effects of radiation are unpredictable
      Maintenance of swallowing exercises are vital in maintaining swallowing function in a
      H&N cancer patient

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                         Donna S. Lundy, PhD, CCC-SLP, BRS-S
                        University of Miami Miller School of Medicine
                                         Miami, FL

J.C. Initial presentation
        71 YOM 5 mos. s/p chemo-radiation therapy for T3N0Mx SCCC of the supraglottis
        NPO and PEG dependent
        Referred for “last ditch” eval. due to “frozen flap” and no expectation for oral diet
                 “failed” MBS
                 “failed” FEES
        Somewhat depressed as he was told he would probably never swallow again
        Retired airline pilot and otherwise very busy

Supraglottic Larynx

        Conservation surgery possible
        Supraglottic laryngectomy
        Dysphagia and aspiration
        Surgical salvage limited to laryngectomy

JC (cont.): Question #1

        What is a frozen flap?
               A. Ice-cold pharyngeal flap
               B. Rigid larynx
               C. Immobile epiglottis
               D. None of the above

JC (cont.): Evaluation

        General appearance: intelligent but depressed man
        Speech/Voice: soft, hoarse vocal quality; appeared in pain when speaking but stated pain
        was much better
        Oral Mechanism:
              Tongue: decreased ROM & strength; no asymmetries; sores observed on soft
        MBS: video attached

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JC (cont.): Question #2

        What is a frozen flap?
               A. Ice-cold pharyngeal flap
               B. Rigid larynx
               C. Immobile epiglottis
               D. None of the above

JC (cont.): Results of MBS

        Limited study due to pt’s anticipatory concerns (coughing/gagging prior to anything
        being observed)
        Reduced base of tongue retraction
        Reduced laryngeal motion
        Minimal epiglottic inversion
        Incomplete cricopharyngeal relaxation
        Trace, sensate penetration & aspiration
        Strategies/Maneuvers: effortful swallow & head position changes w/limited results due to
        pt’s reactions

JC (cont.) Question #3

What are your recommendations based on the MBS?
      A. Remain NPO & repeat MBS when feeling better
      B. Remain NPO & begin aggressive therapy
      C. Begin PO with nectar/honey consistencies & aggressive therapy
      D. Remain NPO & begin desensitization + aggressive therapy

JC (cont.): Therapy
       Therapy initiated w/emphasis on desensitization to tolerating things in his mouth
              Tongue strength & ROM exercises: resistance against tongue depressor; used
              Kay Swallow Station for biofeedback (surface EMG & tongue array systems)
              Base of tongue retraction:
                      Masako maneuver
                      Voluntary tongue retraction
              Laryngeal elevation:
                      Mendelsohn maneuver
                      Falsetto exercises
                      Tongue press
              Swallow maneuvers: effortful + Supraglottic = Super-supraglottic

*Shaker not utilized due to c-spine complaints

JC (cont.): follow-up MBS after 2 mos. therapy           MBS

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JC (cont.) Question #4

What would you recommend based on repeat MBS?
             A. Remain NPO & cont. therapy
             B. Remain NPO & d/c therapy
             C. Increase Oral diet & cont. therapy
             D. None of the above

JC (cont.): Further follow-up

        Continued to progress but ? esophageal narrowing noted vs. inability to take adequate
        amount of barium to distend esophagus; consulted GI who scoped & dilated X3 over 6
        wk. period
        PO increased
               Thin, smooth nectar to pudding consistencies
               Weaning from complete PEG dependency
               Slowly due to pt’s hesitations: 1 can per each 2 wks. as long as weight
               maintained & no other symptoms
               Progressed from 6 to 3 cans per day thru PEG but stale-mated
        Repeat MBS

JC (cont.) Question #5

        What do you recommend now?
              A. NPO & d/c from therapy
              B. Refer back to GI or other medical specialist
              C. Continue current plan
              D. Accept this as maximal level of improvement

JC (cont.) Final Question

        What is a frozen flap?
               A. Ice-cold pharyngeal flap
               B. Rigid larynx
               C. Immobile epiglottis
               D. None of the above

                 Would you do anything different?

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                                 Annette May, MA, CCC-SLP
                              MD Anderson Cancer Center Orlando
                                        Orlando, FL

Patient History

        59 y.o. male
        T4N2c squamous cell carcinoma right base of tongue
        Initial treatment: Chemoradiation
        PEG placed prophylactically
        No pre-tx Speech Pathology evaluation/education (treated elsewhere)
        Residual disease treated w/surgery at another institution 2M post chemo-RT:
                 Right lateral pharyngeal wall/BOT/soft palate resection, right modified radical
                 neck dissection and pectoralis major myocutaneous flap reconstruction
        First MBS done at same facility as surgery (1M post-op):
                 Severe dysphagia reported with gross aspiration
                 NPO rx’d
                 Swallowing rehabilitation rx’d; however pt unable to travel the distance to the
        PCP referred patient for Home Health SLP services; however, never scheduled per

Initial Exam

        First seen at our facility 6M post-op:
                NPO: all nutrition/hydration via PEG
                Tongue deviation to the right with atrophy
                Significantly reduced strength and ROM of the tongue on the right
                Surgical defect of right soft palate and right lateral pharyngeal wall
                Moderate hypernasality with nasal emission
                Mild/moderate dysphonia
                Fiberoptic Endoscopic Evaluation of Swallowing (FEES) study completed


        Questionable area right pharynx (required further
        medical work-up)
        Good instrumental tool to assess anatomic abnormalities
        Limited evaluation of swallow physiology in this case

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        Was there pre-mature spillover to the pharynx or pharyngeal response delay?
        Did the patient aspirate?
        If so, does his cough clear the airway?

        What deficits do you see?
           A. Oral
           B. Pharyngeal
           C. ?Stricture
        Based on information from 1st trial, what would you do next?
           A. Stop Exam/NPO
           B. Volume Modification
           C. Consistency modification
           D. Compensatory strategy
           E. Postural strategy

Treatment Questions
      What are the deficits?
      What exercises could target these deficits?
      Compensatory strategies to use in treatment?
      P.O. trials in treatment?

Treatment Plan
                Tongue-hold (Masako)
        Oral trials with use of compensatory swallow strategies
                Nectar thick liquids
                Super-supraglottic swallow
                Multiple swallows
        Continue nutrition/hydration through tube initially; slowly increasing p.o. of liquids

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Repeat MBS

         Improved airway protection
         Coordinated use of multiple compensatory
         swallow strategies
         Increase p.o. liquid nutrition
         Continue to target same strategies for purees


         Initially resumed liquid diet
         Weaned from feeding tube with assistance of dietician and monitoring of pulmonary
         status by physician
         Slowly upgraded to pureed diet
         Continued to use swallow strategies (supraglottic, effortful, multiple swallows, liquid
         Gained weight; no pulmonary complications
         PEG tube removed!!!

Final Thoughts

         Both instrumental exams helped define anatomical changes and function
         MBS more appropriate in this case to guide treatment plan
         MBS is NOT pass/fail test
         Although no strategies were 100% effective on initial MBS, results guided treatment
         choices and potential for use of strategies to resume p.o.

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                          Linda Stachowiak MS, CCC-SLP, BRS-S
                                MD Anderson Cancer Center
                                 University of South Florida
                                        Orlando, FL

Case History

        44 yr. old male
        T2N2aMo left tonsil
                Transoral excision
                Left radical neck dissection
                Primary Closure
        Course was complicated by a pharyngocutaneous fistula
        Was NPO with dobhoff (N-G) tube feeds for 3 weeks prior to my doing an MBS
        Lost 24 lbs in this time period
        Patient reports more difficulty with solids (won’t go down)
        Coughing and choking with most consistencies
        Oral-Motor Exam:
                Slight left facial droop
                Slight difficulty puckering his lips
                Weak tongue with slow effortful movements
                Vocal quality WNL

        Patient is VERY bothered by the nasogastric tube

MBS Findings:

        Decreased epiglottic inversion
        Decreased hyolaryngeal elevation
        Stasis in the pyriform sinuses
        Reduced UES relaxation

Based on the findings of the oral-motor exam, what question should we be asking ourselves
about the stasis we are seeing in the pyriform sinus?

        Is the stasis in the pyriform sinus unilateral or bilateral?

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What is the best way of assessing unilateral vs. bilateral stasis in the pyriform sinuses during an
       Turn the patient A-P (Anterior- Posterior)
       Check for symmetry of stasis

A-P view to assess symmetry of stasis
       Where is the stasis greater?

When it becomes obvious that the stasis is unilateral, what should your next strategy be?
  A. Head turn to the side of greater stasis (weaker side)
  B. Head turn to the side of less stasis (stronger side)
  C. Head tilt to the weaker side
  D. Head tilt to the stronger side

Head turn to the side of greater stasis (weaker side)

        Rationale: Turning the head towards the weaker side closes off this side, using the
        stronger/intact side for bolus passage
        Lateral view

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Head turn to the side of greater stasis (weaker side)
       Rationale: Turning the head towards the weaker side closes off this side, using the
       stronger/intact side for bolus passage
        A-P view

As the consistency increases from thin to puree consistency, what can we predict will occur with
the stasis in a case with unilateral weakness?

A. The stasis will remain the same
B. The stasis will decrease
C. The stasis will increase

The stasis will increase
  Heavier boluses require more effort to pass through the hypophayrnx

Stasis with puree consistency

What strategy can be implemented in addition to the head turn to reduce puree stasis?

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Questions to ponder:

Should we recommend pulling the nasogastric tube knowing that the head turn/water wash
strategy is effective?
                Patient is young, ambulatory and with no other medical problems
                Pt understands the importance of the postural strategy and it’s effect on
                eliminating aspiration

Do you think that doing an MBS with the N-G tube in place has significant effect on the
efficiency of the swallow?

Leder SB, Suiter DM: Effect of nasogastric tubes on incidence of aspiration. Arch Phys Med
    Rehabil 2008, 89:648-6541.

Wang TG, Wu MC, Chang YC, Hsiao TY, Lien IN: The effect of nasogastric tubes on
   swallowing function in persons with dysphagia following stroke. Arch Phys Med Rehabil
   2006, 87: 1270-1273.

Huggins PS, Tuomi SK, Young C: Effects of nasogastric tubes on the young, normal
   swallowing mechanism. Dysphagia 1999, 14: 157-161.

Dziewas R, Warnecke T, Hamacher C, Oelenberg S, Teismann I, Kraemer C: Do nasogastric
    tubes worsen dysphagia in patients with acute stroke? BMC Neurology 2008, 8: 1-8.

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Mary J. Bacon, MA CCC-SLP, BRS-S is an Associate Professor and Clinical
Educator in the Communication Disorders and Sciences Department, Rush
University Medical Center, Chicago Illinois. She teaches dysphagia
coursework to graduate students at Rush University. She has evaluated and
treated patients with dysphagia for more than 25 years.

Joy Gaziano, MS, CCC-SLP, BRS-S is the Director of Swallowing
Rehabilitation at the Center for Esophageal and Swallowing Disorders at the
University of South Florida. Interests include management of complex
oropharyngeal swallowing disorders, voice problems related to upper
aerodigestive tract disorders, and head and neck cancer voice and
swallowing restoration.

Mario A. Landera, MA, CCC-SLP is currently working at the University of
Miami Miller School of Medicine in the Department of Otolaryngology. He
specializes in head and neck cancer rehabilitation, voice disorders, and
swallowing disorders. This is his third year participating in this panel.

Donna S. Lundy, PhD, CCC-SLP, BRS-S is an associate professor in the
Department of Otolaryngology at University of Miami Miller School of
Medicine. She specializes in the care and management of individuals with
head and neck cancer, dysphagia, and voice disorders. Dr. Lundy actively
participates in a number of multi-institutional research grants.

Annette May, MA, CCC-SLP, is the Speech Pathology Coordinator for
Oncology at M.D. Anderson Cancer Center Orlando. She specializes in the
management of patients with communication and swallowing deficits as a
result of head and neck cancer. She has also participated in functional
outcomes research in this patient population.

Linda Stachowiak MS, CCC-SLP, BRS-S is a speech pathologist with
26 years of clinical experience with a variety of disorders. The last half of
her career has been spent specializing in the area of Head and Neck Cancer,
voice disorders of all etiologies as well as swallowing disorders. She is
presently working as a Speech Pathologist at the MD Anderson Cancer
Center, Orlando, FL. She also is an instructor at the University of South
Florida whereby she teaches the graduate dysphagia course. Ms. Stachowiak
has participated in multi-institutional research in the area of dysphagia and
laryngectomy rehabilitation. She has presented on these topics at the local
state and national level.

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