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Análise quantitativa e a perceção do doente sobre a fonação e deglutição no cancro da orofaringe
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Abstract(s)
O cancro de cabeça e pescoço é o quinto mais comum entre todas as localizações, tendo o da orofaringe, na hipotética associação com a infeção por Vírus do Papiloma Humano (HPV) uma expressão crescente. Para os tumores com esta localização e com comprovada associação com o HPV o tratamento não cirúrgico é preferencial. O impacto da quimioradioterapia na deglutição e voz tem vindo a ser descrito, contudo a relação entre as medidas objetivas de avaliação da fonação e da deglutição e a perceção do doente ainda é controversa.
Assim, o principal objetivo foi compreender qual a relação entre as medidas quantitativas e a perceção do doente com cancro da orofaringe, submetido a tratamento com radio e/ou quimioterapia.
Para ajudar a melhor caracterizar este impacto realizou-se uma revisão sistemática, em agosto de 2020 (capítulo II), acerca do estado da arte englobando todas as publicações que incluíssem estudos sobre a temática acima mencionada. Foram selecionados 25 estudos, mas apenas um deles abordava a área da fonação, sendo os restantes sobre a deglutição. Os métodos de avaliação objetiva selecionados foram essencialmente dois, a videoendoscopia da deglutição e a videofluoroscopia da deglutição, mas os procedimentos para a sua realização e a multiplicidade de questionários utilizados não permitiram a realização de uma correta meta-análise, tornando-se por esta razão desafiante a comparação de resultados. Foi, contudo, possível compilar três principais focos: 1) as medidas fisiológicas; 2) as habilidades oromotoras; e 3) os aspetos relacionados com a segurança na deglutição, aspetos que comprovadamente melhor se correlacionavam com a perceção auto-reportada pelos doentes.
Seguidamente, conduziu-se uma análise qualitativa (capítulo III), com recurso à técnica de entrevista semi-estruturada, dirigida a doentes (Instituto Português de Oncologia do Porto), otorrinolaringologistas (de diferentes hospitais portugueses) e terapeutas da fala Análise quantitativa e a perceção do doente sobre a fonação e deglutição no cancro da orofaringe (de diferentes hospitais portugueses) com experiência no tratamento e no acompanhamento de doentes com este tipo de patologia. Das entrevistas emergiram dois temas principais: a deglutição e a voz. No que à deglutição diz respeito, aspetos como seleção dos alimentos, o tempo da refeição, o prazer com a alimentação, o desejo de comer, a restrição de contactos sociais e familiares, o receio e a incerteza, bem como a presença de sintomas relacionados com disfagia evidenciaram ter um impacto negativo na qualidade de vida (QdV). No que se refere à voz, as alterações qualitativas, a diminuição da eficácia comunicativa e o número de interações a nível social, laboral e familiar, bem como as dificuldades sentidas, por não se conseguirem fazer compreender pelo recetor, especialmente em locais ruidosos ou ao telefone, foram os aspetos mais notórios. Os dados obtidos foram semelhantes entre os três grupos (doentes, otorrinolaringologistas e terapeutas da fala), ou seja, os profissionais de saúde manifestaram ter conhecimento sobre as principais sequelas, mas não em termos de intensidade e da experiência de viver com disfagia e disfonia.
Prosseguiu-se depois com um estudo transversal (capítulo IV) numa coorte de 38 doentes oncológicos, do Instituto Português de Oncologia do Porto, tratados com quimioradioterapia, com intenção curativa e livres de doença há pelo menos um ano, a fim de caracterizar a perceção auto-reportada pelos doentes e a sua relação com os dados sociodemográficos e clínicos. Os resultados dos questionários demonstraram alterações tanto na QdV geral, como na QdV relacionada com a disfagia e/ou a disfonia, sendo que quando utilizados instrumentos específicos para sintomas, as alterações funcionais foram mais evidentes. Não foram, contudo, encontradas correlações consistentes entre os dados auto-reportados e as variáveis sociodemográficas e clínicas. Apesar disso, este estudo permitiu compreender que mesmo quando a quimioradioterapia não é dirigida à região laríngea, observou-se um claro comprometimento nas funções de fonação e deglutição em que este órgão está envolvido.
No final do documento fez-se uma análise mais detalhada da relação entre a avaliação objetiva e subjetiva. Para tal foi realizado um estudo transversal (capítulo V), com 38 doentes, do Instituto Português de Oncologia do Porto, submetidos a quimioradioterapia por tumores da orofaringe, tendo todos sido submetidos a avaliação endoscópica da deglutição e responderam a três questionários (EORTC-C30, EORTC-HN43 e SWALQOL).
A disfagia revelou-se uma sequela relevante e por isso, de suma importância quando analisadas as sequelas do tratamento destes doentes. A presença de resíduos para Análise quantitativa e a perceção do doente sobre a fonação e deglutição no cancro da orofaringe todas as consistências ingeridas, indiciaram ineficácia dos mecanismos de limpeza faringolaríngea, associada a múltiplas deglutições por bolus e a maior risco de aspiração.
O aumento da viscosidade teve impacto no aumento dos resíduos. Apesar dos achados, a tosse foi um sintoma pouco frequente. Observou-se também um tempo de resposta faríngea aumentado e uma diminuição do tempo de encerramento das vias aéreas inferiores. Encontraram-se correlações entre o resultado global do HN43 e as variáveis de segurança e de eficiência da deglutição. Para as variáveis fisiológicas não foram encontradas correlações. Relativamente ao questionário SWAL-QOL, apesar de identificar alterações da deglutição não foi possível constatar um padrão de correlações com os dados da videoendoscopia da deglutição. O resultado global do C30 e do HN43 relacionaram-se com as variáveis de segurança. Para as variáveis de eficiência algumas das escalas dos três questionários mostraram correlações significativas. Apesar da inconsistência destas correlações, tanto a avaliação objetiva como subjetiva indicaram alteração da função de deglutição.
A mesma coorte de doentes (capítulo VI), do Instituto Português de Oncologia do Porto, foi sujeita a avaliação vocal, por meio de análise acústica, avaliação áudio-percetiva com classificação pela GRBAS e análise da ressonância, bem como através do VHI-9i. Os dados recolhidos evidenciaram perturbação vocal, indicativa de disfonia. Contudo, apenas os doentes com incapacidade severa medida pelo VHI-9i obtiveram valores de índice de severidade de disfonia indicativos de perturbação. De uma forma global, os doentes que realizaram quimioradioterapia por cancro da orofaringe apresentaram shimmer superior a 3% e jitter superior a 1% e tempo máximo de fonação inferior a 10 segundos. Os valores de F0 também se mostraram alterados. O tempo após tratamento e a realização de terapia da fala tiveram um impacto positivo nos resultados. Os valores de análise acústica, mesmo após um período considerado longo mantiveram-se perturbados.
As medidas de intensidade e de ruído (HNR) não foram eficazes na deteção de disfonia, mas pela análise dos resultados de índice de severidade de disfonia mais de 10% dos participantes no presente estudo têm disfonia. A avaliação com a GRBAS identificou mais de 31% de alterações, bem como na análise da ressonância. O VHI-9i identificou 50% de participantes com incapacidade vocal, contudo na correlação com os dados objetivos, as avaliações parecem mostrar dados distintos, mas complementares.
Concluiu-se que apesar das inconsistências entre a avaliação objetiva e subjetiva, observada na revisão sistemática, alguns parâmetros fisiológicos, biomecânicos e de Análise quantitativa e a perceção do doente sobre a fonação e deglutição no cancro da orofaringe segurança evidenciaram uma relação com a perceção do doente. Quer os doentes, quer os profissionais de saúde (terapeutas e otorrinolaringologistas) reportaram sequelas funcionais na fonação e na deglutição semelhantes. Os questionários de avaliação da perceção permitiram recolher estes dados, facilitando a monitorização e uma ação preventiva no tratamento destes doentes. Dos dados recolhidos da amostra estudada observou-se pobre correlação entre as medidas objetivas e subjetivas da deglutição e da fonação.
Head and neck cancer is the fifth most common cancer among all locations, with oropharyngeal cancer, as a hypothetic result of Human Papilloma Virus (HPV) infection, having an increasing expression. Chemoradiotherapy is a selected treatment option in some of these tumors. The effects of chemoradiotherapy on swallowing and voice have been described, but the relationship between objective phonation and swallowing assessment measures and patient perception are still controversial. Thus, we aimed to understand the relationship between quantitative measures and the patient’s perception with oropharyngeal cancer undergoing treatment with radiotherapy and chemotherapy. Initially, a systematic review was carried out in August 2020 (chapter II) to understand the state of the art regarding the studies developed on the mentioned topic. Twenty-five studies were selected, but only one of the studies addressed the phonation area, and all the others were about swallowing. Objective assessment is until now mainly analyzed by two methods, swallowing videoendoscopy or swallowing videofluoroscopy. However, these procedures due their performance and the multiplicity of questionnaires used did not allow the performance of a meta-analysis and made challenging the comparing of results. Nevertheless, it was possible to compile three main targets: 1) physiological measures; 2) oromotor skills; and 3) aspects related to swallowing safety that best correlated with patient self-reported perception. We conducted a qualitative analysis (chapter III), using a semi-structured interviews technique, directed to the included patients (Oporto Oncology Portuguese Institute), ENT doctors (different Portuguese Hospitals) and speech language pathologists (different Portuguese Institutions) with experience in treating and monitoring patients with this type of pathology. Two main themes emerged from the interviews: swallowing and voice. Regarding swallowing, aspects such as food selection, meal time, eating pleasure, appetite, social and family contacts, fear, and uncertainty, as well as the presence of symptoms related to dysphagia seem to have a negative impact on quality of life (QoL). About voice, changes in vocal quality, decreased communicative effectiveness in social, work, and familiar context as well as the number of interactions, and difficulties experienced due to not be understood by the message receptor especially in noisy environments or by phone are important limitations. Data was obtained in the three groups (patients, ENT doctors, and speech therapists), that is, health professionals have knowledge about the main sequelae, however not in terms of intensity. We continued with a cross-sectional study (chapter IV) with a cohort of 38 oropharyngeal cancer patients from Oporto Oncology Portuguese Institute treated with chemoradiotherapy, with curative intent and disease free for one year, were included to analyze patient’s self-reported perception and its relationship with sociodemographic and clinical data. The results of the questionnaires indicated changes in both general QoL and QoL related to dysphagia and/or dysphonia, with symptom-specific instruments detecting more changes. No consistent correlations were found between self-reported data and sociodemographic and clinical variables. Nevertheless, this study allowed us to understand that although chemoradiotherapy were not directed to the laryngeal region, were observed relevant disturbances in swallowing and phonation. In the final part of the document, the author carried out a proper analysis about the relationship between objective and subjective evaluations. A cross-sectional study (chapter V) all patients included, from Oporto Oncology Portuguese Institute, underwent endoscopic swallowing assessment and answered three questionnaires (EORTC-C30, EORTC-HN43 and SWAL-QOL). Dysphagia proved to be a prevalent sequela and therefore of paramount importance in the treatment of these patients. The presence of residues for all ministered consistencies indicated inefficient pharyngolaryngeal cleanliness, associated with multiple bolus swallows and increased risk of aspiration. Increased viscosity had an impact on increased residue. Despite these findings, cough was an infrequent symptom. In addition, increased pharyngeal response time and decreased lower airway closure times were observed. Correlations were found between the overall HN43 score and the swallowing safety and efficiency variables. For the physiological variables no correlations were found. SWAL-QOL questionnaire identify well swallowing changes but was not possible to find a correlation pattern with the fiberoptic endoscopic evaluation of swallowing results. Overall results of C30 and HN43 questionnaires related to the safety variables. For the efficiency variables of the scales of the three questionnaires showed significant correlations. Despite correlations inconsistency, both objective and subjective assessments indicated altered swallowing. The same cohort of oropharyngeal patients (chapter VI), from the Oporto Oncology Portuguese Institute, was submitted to vocal assessment by acoustic analysis, audio perceptive evaluation with GRBAS classification, and resonance analysis methods, as well as with VHI-9i. Collected data showed vocal disturbance, indicative of dysphonia. However, only patients with severe disability measured by the VHI-9i obtained Dysphagia Severity Index values indicative of disorder. Overall, patients who underwent chemoradiotherapy for oropharyngeal cancer had shimmer greater than 3%, jitter greater than 1%, and maximum phonation time less than 10 seconds. F0 values were also found to be altered. Time after treatment and speech therapy performance had a positive effect on the results. Acoustic analysis values, even after a long period after treatment remained disturbed. Loudness and harmonic-to-noise ratio measures were not effective in detecting dysphonia, but analyzing Dysphagia Severity Index results, more than10% of participants have dysphonia. The assessment with GRBAS identified over 31% of changes, as resonance analyses. VHI-9i identified 50% of participants with vocal impairment, however in correlation with objective data, the assessments seem to show different results. In conclusion, despite de inconsistencies between objective and subjective assessment observed in the systematic review, some physiological, biomechanics and safety parameters showed a relationship with the patient’s perception. Both patients and healthcare professionals (therapist and otolaryngologists) reported similar functional sequelae in phonation and swallowing. The questionnaires to assess the patient’s perception allow the collection of these data, facilitating monitoring and preventive action in the treatment of these patients. The data collection from the sample studied showed a poor correlation between objective and subjective measures of phonation and swallowing.
Head and neck cancer is the fifth most common cancer among all locations, with oropharyngeal cancer, as a hypothetic result of Human Papilloma Virus (HPV) infection, having an increasing expression. Chemoradiotherapy is a selected treatment option in some of these tumors. The effects of chemoradiotherapy on swallowing and voice have been described, but the relationship between objective phonation and swallowing assessment measures and patient perception are still controversial. Thus, we aimed to understand the relationship between quantitative measures and the patient’s perception with oropharyngeal cancer undergoing treatment with radiotherapy and chemotherapy. Initially, a systematic review was carried out in August 2020 (chapter II) to understand the state of the art regarding the studies developed on the mentioned topic. Twenty-five studies were selected, but only one of the studies addressed the phonation area, and all the others were about swallowing. Objective assessment is until now mainly analyzed by two methods, swallowing videoendoscopy or swallowing videofluoroscopy. However, these procedures due their performance and the multiplicity of questionnaires used did not allow the performance of a meta-analysis and made challenging the comparing of results. Nevertheless, it was possible to compile three main targets: 1) physiological measures; 2) oromotor skills; and 3) aspects related to swallowing safety that best correlated with patient self-reported perception. We conducted a qualitative analysis (chapter III), using a semi-structured interviews technique, directed to the included patients (Oporto Oncology Portuguese Institute), ENT doctors (different Portuguese Hospitals) and speech language pathologists (different Portuguese Institutions) with experience in treating and monitoring patients with this type of pathology. Two main themes emerged from the interviews: swallowing and voice. Regarding swallowing, aspects such as food selection, meal time, eating pleasure, appetite, social and family contacts, fear, and uncertainty, as well as the presence of symptoms related to dysphagia seem to have a negative impact on quality of life (QoL). About voice, changes in vocal quality, decreased communicative effectiveness in social, work, and familiar context as well as the number of interactions, and difficulties experienced due to not be understood by the message receptor especially in noisy environments or by phone are important limitations. Data was obtained in the three groups (patients, ENT doctors, and speech therapists), that is, health professionals have knowledge about the main sequelae, however not in terms of intensity. We continued with a cross-sectional study (chapter IV) with a cohort of 38 oropharyngeal cancer patients from Oporto Oncology Portuguese Institute treated with chemoradiotherapy, with curative intent and disease free for one year, were included to analyze patient’s self-reported perception and its relationship with sociodemographic and clinical data. The results of the questionnaires indicated changes in both general QoL and QoL related to dysphagia and/or dysphonia, with symptom-specific instruments detecting more changes. No consistent correlations were found between self-reported data and sociodemographic and clinical variables. Nevertheless, this study allowed us to understand that although chemoradiotherapy were not directed to the laryngeal region, were observed relevant disturbances in swallowing and phonation. In the final part of the document, the author carried out a proper analysis about the relationship between objective and subjective evaluations. A cross-sectional study (chapter V) all patients included, from Oporto Oncology Portuguese Institute, underwent endoscopic swallowing assessment and answered three questionnaires (EORTC-C30, EORTC-HN43 and SWAL-QOL). Dysphagia proved to be a prevalent sequela and therefore of paramount importance in the treatment of these patients. The presence of residues for all ministered consistencies indicated inefficient pharyngolaryngeal cleanliness, associated with multiple bolus swallows and increased risk of aspiration. Increased viscosity had an impact on increased residue. Despite these findings, cough was an infrequent symptom. In addition, increased pharyngeal response time and decreased lower airway closure times were observed. Correlations were found between the overall HN43 score and the swallowing safety and efficiency variables. For the physiological variables no correlations were found. SWAL-QOL questionnaire identify well swallowing changes but was not possible to find a correlation pattern with the fiberoptic endoscopic evaluation of swallowing results. Overall results of C30 and HN43 questionnaires related to the safety variables. For the efficiency variables of the scales of the three questionnaires showed significant correlations. Despite correlations inconsistency, both objective and subjective assessments indicated altered swallowing. The same cohort of oropharyngeal patients (chapter VI), from the Oporto Oncology Portuguese Institute, was submitted to vocal assessment by acoustic analysis, audio perceptive evaluation with GRBAS classification, and resonance analysis methods, as well as with VHI-9i. Collected data showed vocal disturbance, indicative of dysphonia. However, only patients with severe disability measured by the VHI-9i obtained Dysphagia Severity Index values indicative of disorder. Overall, patients who underwent chemoradiotherapy for oropharyngeal cancer had shimmer greater than 3%, jitter greater than 1%, and maximum phonation time less than 10 seconds. F0 values were also found to be altered. Time after treatment and speech therapy performance had a positive effect on the results. Acoustic analysis values, even after a long period after treatment remained disturbed. Loudness and harmonic-to-noise ratio measures were not effective in detecting dysphonia, but analyzing Dysphagia Severity Index results, more than10% of participants have dysphonia. The assessment with GRBAS identified over 31% of changes, as resonance analyses. VHI-9i identified 50% of participants with vocal impairment, however in correlation with objective data, the assessments seem to show different results. In conclusion, despite de inconsistencies between objective and subjective assessment observed in the systematic review, some physiological, biomechanics and safety parameters showed a relationship with the patient’s perception. Both patients and healthcare professionals (therapist and otolaryngologists) reported similar functional sequelae in phonation and swallowing. The questionnaires to assess the patient’s perception allow the collection of these data, facilitating monitoring and preventive action in the treatment of these patients. The data collection from the sample studied showed a poor correlation between objective and subjective measures of phonation and swallowing.