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Modified Mondays: STOP BEFORE YOU POP

Head and neck cancer is complicated and messy. There’s no cookie cutter manner in which cancer grows, and you can never be certain as to what masses, edema, and surgery will do to the physiology of swallowing and respiration. SLPs must work closely with ENTs during cancer treatment to ensure the patient is maintaining a patent airway if the patient is trialing a PMV. In addition, SLPs must be very careful in their methodology of trialing PMVs, starting with assessment using finger occlusion to help determine airway patency.

In today’s Modified Monday, we have a patient who was diagnosed with pharyngeal cancer; specifically, a mass on the anterior side of the epiglottis. The patient had been diagnosed with this cancer the previous month at a different facility. After diagnosis, a trach was placed and soon after successful PMV trials occurred. Since the patient had tolerated PMV trials just one month before, the current facility SLP decided to perform trials as well, but the patient was not able to breathe with the PMV.

At the start of the MBSS, we see abnormal anatomy characterized by a large soft tissue mass anterior to the epiglottis. This fills the vallecular space and pushes the epiglottis to the posterior pharyngeal wall at rest. After a small sip of thin barium is provided, the patient clearly has an impacted swallow from the cancer. In the video clip, you can see that the cancer is not only impeding liquid from flowing through the pharynx, but that there is no patent upper airway. The epiglottis and the mass take up the entire pharynx, and there isn’t any breathing room. It’s no surprise that the patient was not tolerating the PMV.

If someone with head and neck cancer has decreased tolerance of the PMV and/or has valve back pressure…STOP trials. Have an ENT provide direct visualization of the structures to ensure a patent airway before you POP the PMV back on.


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