Heather Starmer is a Clinical Professor and Director of the Head and Neck Cancer Speech and Swallowing Rehabilitation Center. She is a Board Certified Specialist in Swallowing and Swallowing Disorders. in 2023 she was awarded the prestigious Fellow designation by the American Speech Language and Hearing Association (ASHA).

Prior to joining the faculty at Stanford University, Professor Starmer served as the lead of the head and neck cancer rehabilitation program at Johns Hopkins University.
She graduated from California State University at Long Beach in 1998 with a BA in Communicative Disorders and earned her MA from the University of Pittsburgh in 2000. She has pursued doctoral studies at the University of Liverpool with anticipated completion of her PhD in Applied Health Research in 2024. Her doctoral dissertation focused on the assessment of head and neck lymphedema with a particular emphasis on the patient experience and quality of life.

Professor Starmer 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.

Professor Starmer'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. She regularly collaborates with colleagues around the globe to develop innovative solutions to challenges encountered by head and neck care teams and the patients they serve.

Professor Starmer 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 locally, nationally, and internationally. She teaches a graduate level course in swallowing and swallowing disorders at the California State University East Bay. She is a member of multiple professional societies including the American Speech Language Hearing Association, the Dysphagia Research Society, the American Head and Neck Society, and the American Bronchoesophagologic Society. She serves on the boards of the American Board of Swallowing and Swallowing disorders (ABSSD), American Head and Neck Society (AHNS), Dysphagia Research Society (DRS), and the Head and Neck Cancer Alliance (HNCA).

Academic Appointments

  • Clinical Professor, Otolaryngology (Head and Neck Surgery)

Administrative Appointments

  • Director, Head and Neck Cancer Speech and Swallowing Rehabilitation, Stanford University (2014 - Present)

Honors & Awards

  • Fellow of the Association, American Speech Language Hearing Association (ASHA) (2023)

Boards, Advisory Committees, Professional Organizations

  • Member, American Broncoesophagologic Society (ABEA) (2024 - Present)
  • Board member, Head and Neck Cancer Alliance (HNCA) (2023 - Present)
  • Board Member, American Board on Swallowing and Swallowing Disorders (2020 - Present)
  • Member, American Head and Neck Society - Prevention and Early Detection Committee (2013 - 2019)
  • Board member, American Head and Neck Society (2010 - Present)
  • Member, Dysphagia Research Society (2010 - Present)
  • Member, American Speech Language Hearing Association Special Interest Group 3 - Voice Disorders (2009 - Present)
  • Member, American Speech Language Hearing Association Special Interest Group 13 -Swallowing disorders (2009 - Present)
  • Member, American Speech Language Hearing Association (2000 - Present)

Professional Education

  • BA, California State University - Long Beach, Communicative Disorders (1998)
  • MA, University of Pittsburgh, Communication Science and Disorders (2000)
  • Certificate, Johns Hopkins University, Clinical Investigation (2010)

Current Research and Scholarly Interests

Heather’s areas of research interest include investigation of strategies to enhance patient adherence to rehabilitation plans during head and neck cancer treatment, evaluation of communication and swallowing outcomes after Transoral Robotic Surgery (TORS), and assessment of voice outcomes after thyroid surgeries.

Clinical Trials

  • Investigation of Two Swallowing Therapy Models During Radiation Therapy for Head and Neck Cancer Not Recruiting

    Vibrent Health is partnering with Stanford Cancer Center to conduct a randomized control trial (RCT) using mobile health technology to enhance adherence and improve swallowing outcomes in patients undergoing radiation therapy for head and neck cancer.

    Stanford is currently not accepting patients for this trial. For more information, please contact Nikita Bedi, 650-723-5957.

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  • Multispectral Imaging to Characterize Patterns of Vascular Supply Within Lymphoepithelial Mucosa in Oropharyngeal Cancer Not Recruiting

    The purpose of this study is to characterize the blood supply at the base of the tongue and within the tonsil region. We hypothesize that high-resolution Narrow Band Imaging (NBI) will improve the diagnosis of oropharyngeal carcinoma (OPC). The goal is to provide the better assessment of tumor and thus providing better preoperative expectations to patients with OPC or tumor extent prior to radiation therapy.

    Stanford is currently not accepting patients for this trial. For more information, please contact Nikta Bedi, 650-723-5957.

    View full details

All Publications

  • Characterizing the Validity of Using VASES to Derive DIGEST-FEES Grades. Folia phoniatrica et logopaedica : official organ of the International Association of Logopedics and Phoniatrics (IALP) Curtis, J. A., Tabor Gray, L., Arrese, L., Borders, J. C., Starmer, H. 2024: 1-10


    Visual Analysis of Swallowing Efficiency and Safety (VASES) and Dynamic Imaging Grade of Swallowing Toxicity for Flexible Endoscopic Evaluation of Swallowing (DIGEST-FEES) are two complimentary methods for assessing swallowing during FEES. Whereas VASES is intended to facilitate trial-level ratings of pharyngeal residue, penetration, and aspiration, DIGEST-FEES is intended to facilitate protocol-level impairment grades of swallowing safety and efficiency. The aim of this study was to assess the validity of using VASES to derive DIGEST-FEES impairment grades.DIGEST-FEES grades were blindly analyzed from 50 FEES - first using the original DIGEST-FEES grading method (n = 50) and then again using a VASES-derived DIGEST-FEES grading method (n = 50). Weighted Kappa (κw) and absolute agreement (%) were used to assess the relationship between the original DIGEST-FEES grades and VASES-derived DIGEST-FEES grades. Spearman's correlations assessed the relationship between VASES-derived DIGEST-FEES grades with measures of construct validity.Substantial agreement (κw = 0.76-0.83) was observed between the original and VASES-derived grading methods, with 60-62% of all DIGEST-FEES grades matching exactly, and 92-100% of DIGEST-FEES grades within one grade of each other. Furthermore, the strength of the relationships between VASES-derived DIGEST-FEES grades and measures of construct validity (r = 0.34-0.78) were similar to the strength of the relationships between original DIGEST-FEES grades and the same measures of construct validity (r = 0.34-0.83).Findings from this study demonstrate substantial agreement between original and VASES-derived DIGEST-FEES grades. Using VASES to derive DIGEST-FEES also appears to maintain the same level of construct validity established with the original DIGEST-FEES. Therefore, clinicians and researchers may consider using VASES to increase the transparency and standardization of DIGEST-FEES ratings. Future research should seek to replicate these findings and explore the simultaneous use of VASES and DIGEST-FEES in a greater sampling of raters and across other patient populations.

    View details for DOI 10.1159/000538935

    View details for PubMedID 38631299

  • Patient Experience of Head and Neck Surgery With Free Flap Reconstruction. JAMA otolaryngology-- head & neck surgery Dattilo, L. W., Russell, T. I., Warinner, C. B., Starmer, H., Annino, D. J., Goguen, L. A., Sethi, R. K., Uppaluri, R., Windon, M. J., Bergmark, R. W., Rettig, E. M. 2024


    Importance: Major head and neck surgery with microvascular free tissue transfer reconstruction is complex, with considerable risk of morbidity. Little is known about patients' experiences, including decision-making prior to, and regret following, free flap surgery.Objective: To characterize patient experiences and decision regret of patients undergoing head and neck reconstructive free flap surgery.Design, Setting, and Participants: This mixed-methods cohort study comprising semistructured interviews was conducted June to August 2021 at a single tertiary academic cancer center. Participants underwent head and neck reconstructive surgery with microvascular free tissue transfer (flap) more than 3 months before recruitment (range, 3 months to 4 years). Interview transcripts were qualitatively analyzed for themes. Participants also completed a Decision Regret Scale questionnaire.Exposure: Microvascular free flap surgery for head and neck reconstruction.Main Outcomes and Measures: Thematic analysis of interviews, decision regret score.Results: Seventeen participants were interviewed. Median (IQR) age was 61 (52-70) years. Overall, 7 participants were women (49%), and 10 of 17 were men (59%). The most common free flap was fibula (8/17, 47%). Three major themes with 9 subthemes were identified: theme 1 was the tremendous effect of preoperative counseling on surgical decision-making and satisfaction, with subthemes including (1) importance of clinical care team counseling on decision to have surgery; (2) emotional context colors preoperative understanding and retention of information; (3) expectation-setting affects satisfaction with preoperative counseling; and (4) desire for diversified delivery of preoperative information. Theme 2 was coexisting and often conflicting priorities, including (1) desire to survive above all else, and (2) desire for quality of life. Theme 3 was perception of surgery as momentous and distressing, including (1) surgery as a traumatic event; (2) centrality of mental health, emotional resolve, and gratitude to enduring surgery and recovery; and (3) sense of accomplishment in recovery. On the Decision Regret Scale, most participants had no regret (n=8, 47%) or mild regret (n=5, 29%); 4 had moderate-to-severe regret (24%).Conclusions and Relevance: In this mixed-methods cohort study, patient experiences surrounding major head and neck reconstructive free flap surgery were described. Opportunities to improve support for this complex and vulnerable population, and to mitigate decision regret, were identified.

    View details for DOI 10.1001/jamaoto.2023.4750

    View details for PubMedID 38386356

  • Development of a head and neck lymphoedema specific quality of life tool: The Comprehensive Assessment of Lymphoedema Impact in the Head and Neck. Head & neck Starmer, H. M., Patterson, J., Young, B., Fleming, J., Cherry, M. G. 2024


    To develop a head and neck lymphoedema (HNL) specific quality of life (QoL) instrument to assess physical, functional, and social/emotional impacts of HNL.Instrument candidate items were reviewed by patients with HNL and clinicians and rated for importance, clarity, and invasiveness. The Content Validity Ratio was applied for item reduction. Three-step cognitive interviews were conducted with HNL patients to validate the items, survey format, and instructions.Initially, 130 candidate questions were developed. Following item reduction, 52 items progressed to three-step cognitive interviews. Following cognitive interviews, the Comprehensive Assessment of Lymphoedema Impact in Head and Neck (CALI-HaN) included 33 items; 1 global, 10 physical, 7 functional, and 15 emotional.Physical, functional, and socioemotional effects need to be considered when measuring QoL in patients with HNL. This study describes initial development of the CALI-HaN, an instrument that shows promise for clinical and research applications following future validation.

    View details for DOI 10.1002/hed.27704

    View details for PubMedID 38380786

  • Head and neck lymphedema and quality of life: the patient perspective. Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer Starmer, H. M., Cherry, M. G., Patterson, J., Fleming, J., Young, B. 2023; 31 (12): 696


    PURPOSE: Head and neck lymphedema (HNL) is common after head and neck cancer (HNC). This study aimed to explore quality of life (QoL) in patients with HNL to guide the development of a patient-reported QoL measure.METHODS: We conducted semi-structured interviews with 22 HNC survivors with HNL. Interviews explored participants' experiences of living with HNL. Analysis of interview transcripts drew on qualitative content analysis to ensure themes were grounded in patient experience.RESULTS: Two main themes were established: "I want to live my life" and "It was like things were short-circuited." These themes encompassed the substantial disruption patients attributed to the HNL and their desire to normalize life.CONCLUSIONS: Understanding the impact of HNL on individual patients may be critical to optimizing treatment strategies to improve the physical burden of HNL and QoL. This study provides the framework for developing a patient-reported HNL QoL measure.IMPLICATIONS FOR CANCER SURVIVORS: The development of an HNL-specific QoL measure, grounded in the patient perspective, may provide cancer care teams with a tool to better understand HNL's impact on each patient to tailor patient-centered care and optimize QoL outcomes.

    View details for DOI 10.1007/s00520-023-08150-2

    View details for PubMedID 37962667

  • Use of the G8 Geriatric Screening Tool in Surgical Head and Neck Cancer Patients Requiring Rehabilitation: A Multisite Investigation. The Annals of otology, rhinology, and laryngology Palmer, A. D., Starmer, H., Sathe, N., Yao, T. J., Bolognone, R. K., Edwards, J., Crino, C., Kizner, J., Graville, D. J. 2023: 34894231191869


    OBJECTIVES: The G8 is a well-validated screening test for older cancer patients. The current study was undertaken to determine whether the G8 is predictive of short-term post-operative outcomes after head and neck cancer (HNC) surgery.METHODS: Consecutive patients aged 65years or more and referred for a preoperative assessment by a speech-language pathologist were consecutively screened by clinicians at 2 academic medical centers using the G8. The G8 was used to screen for vulnerability prior to surgery. Patients were deemed vulnerable if they had a total G8 score ≤14 according to published guidelines. Data were also collected on demographic characteristics, tumor staging, post-operative course, and tracheostomy and feeding tube (FT) status.RESULTS: Ninety patients were consecutively screened during the study period. Using the G8, 64% of the patients were deemed vulnerable. Vulnerable patients differed significantly from non-vulnerable patients with regard to age, health, tumor stage, and baseline dysphagia, and underwent more extensive surgery. Postoperatively, vulnerable patients had a significantly longer hospital length of stay (LOS; 10.17 vs 5.50days, respectively, P<.001), were less likely to discharge home (76% vs 94%, P=.044), and were more likely to be FT dependent for over a month (54% vs 21%, P=.006) compared to non-vulnerable patients. In regression models, controlling for T-stage and surgical variables, the G8 independently predicted 2 post-operative outcomes of interest, namely LOS and FT dependency.CONCLUSIONS: The G8 may be a useful screening tool for identifying older adults at risk of a protracted postoperative medical course after HNC surgery. Future research should aim to identify the optimal screening protocol and how this information can be incorporated into clinical pathways to enhance the post-operative outcomes of older HNC patients.

    View details for DOI 10.1177/00034894231191869

    View details for PubMedID 37551009

  • Expert Consensus Statement: Management of Dysphagia in Head and Neck Cancer Patients. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Kuhn, M. A., Gillespie, M. B., Ishman, S. L., Ishii, L. E., Brody, R., Cohen, E., Dhar, S. I., Hutcheson, K., Jefferson, G., Johnson, F., Rameau, A., Sher, D., Starmer, H., Strohl, M., Ulmer, K., Vaitaitis, V., Begum, S., Batjargal, M., Dhepyasuwan, N. 2023; 168 (4): 571-592


    To develop an expert consensus statement (ECS) on the management of dysphagia in head and neck cancer (HNC) patients to address controversies and offer opportunities for quality improvement. Dysphagia in HNC was defined as swallowing impairment in patients with cancers of the nasal cavity, paranasal sinuses, nasopharynx, oral cavity, oropharynx, larynx, or hypopharynx.Development group members with expertise in dysphagia followed established guidelines for developing ECS. A professional search strategist systematically reviewed the literature, and the best available evidence was used to compose consensus statements targeted at providers managing dysphagia in adult HNC populations. The development group prioritized topics where there was significant practice variation and topics that would improve the quality of HNC patient care if consensus were possible.The development group identified 60 candidate consensus statements, based on 75 initial proposed topics and questions, that focused on addressing the following high yield topics: (1) risk factors, (2) screening, (3) evaluation, (4) prevention, (5) interventions, and (6) surveillance. After 2 iterations of the Delphi survey and the removal of duplicative statements, 48 statements met the standardized definition for consensus; 12 statements were designated as no consensus.Expert consensus was achieved for 48 statements pertaining to risk factors, screening, evaluation, prevention, intervention, and surveillance for dysphagia in HNC patients. Clinicians can use these statements to improve quality of care, inform policy and protocols, and appreciate areas where there is no consensus. Future research, ideally randomized controlled trials, is warranted to address additional controversies related to dysphagia in HNC patients.

    View details for DOI 10.1002/ohn.302

    View details for PubMedID 36965195

  • Internal oedema and dysphagia characteristics in patients with head and neck cancer. Clinical otolaryngology : official journal of ENT-UK ; official journal of Netherlands Society for Oto-Rhino-Laryngology & Cervico-Facial Surgery Starmer, H. M., Hutcheson, K., Patterson, J. 2023

    View details for DOI 10.1111/coa.14046

    View details for PubMedID 36918287

  • Letter to the Editor re: Intra and interobserver agreement of the Dynamic Imaging Grade of Swallowing Toxicity Scale (DIGEST) in fiberoptic endoscopic evaluation of swallowing (FEES): the importance of observer-tailored training. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery Hutcheson, K. A., Starmer, H. 2023

    View details for DOI 10.1007/s00405-023-07902-4

    View details for PubMedID 36912933

  • Head and Neck Virtual Coach: A Randomized Control Trial of Mobile Health as an Adjunct to Swallowing Therapy During Head and Neck Radiation. Dysphagia Starmer, H. M., Klein, D., Montgomery, A., Goldsmith, T., McCarroll, L., Richmon, J., Christopher Holsinger, F., Beadle, B., Jain, P. 2022


    Dysphagia is a common consequence of head and neck radiation and may be mitigated by performance of swallowing exercises during radiation treatment. Given historically poor adherence to such exercise protocols, we created a mobile health application, HNC Virtual Coach as an adjunct to standard clinical care. This randomized control trial investigated the impact of HNC Virtual Coach on adherence as well as swallowing outcomes by comparing those using the mobile app to those receiving only standard clinical care and paper logs. Both treatment groups were provided with the same exercise protocol as well as the same baseline educational information. Outcome measures included adherence rates, physiologic measures obtained during a Modified Barium Swallow Study (PAS, MBS-ImP, DIGEST), patient-reported outcomes (MDADI), diet levels (FOIS, PSS-HN), and quality of information received (INFO-25). Patients using the HNC Virtual Coach tended to have better adherence to treatment recommendations during radiation therapy. Increased adherence was associated with better patient-reported quality of life, but not physiologic function 2-3months following completion of radiation. Results suggest that a mobile health application may provide benefit for some patients undergoing head and neck radiation.

    View details for DOI 10.1007/s00455-022-10506-5

    View details for PubMedID 35960394

  • Transoral Robotic Surgery for Recurrent Tumors of the Upper Aerodigestive Tract (RECUT): An International Cohort Study. Journal of the National Cancer Institute Hardman, J. C., Holsinger, F. C., Brady, G. C., Beharry, A., Bonifer, A. T., D'Andrea, G., Dabas, S. K., de Almeida, J. R., Duvvuri, U., Floros, P., Ghanem, T. A., Gorphe, P., Gross, N. D., Hamilton, D., Kurukulasuriya, C., Larsen, M. H., Lin, D. J., Magnuson, J. S., Meulemans, J., Miles, B. A., Moore, E. J., Pantvaidya, G., Roof, S., Rubek, N., Simon, C., Subash, A., Topf, M. C., Van Abel, K. M., Vander Poorten, V., Walgama, E. S., Greenlay, E., Potts, L., Balaji, A., Starmer, H. M., Stephen, S., Roe, J., Harrington, K., Paleri, V. 2022


    BACKGROUND: Transoral robotic surgery (TORS) is an emerging minimally invasive surgical treatment for residual, recurrent, and new primary head and neck cancers in previously irradiated fields, with limited evidence for its oncological effectiveness.METHODS: A retrospective observational cohort study of consecutive cases performed in 16 high-volume international centers before August 2018 was conducted (registered at [NCT04673929] as the RECUT study). Overall survival (OS), disease-free survival, disease-specific survivals (DSS), and local control (LC) were calculated using Kaplan-Meier estimates, with subgroups compared using log-rank tests and Cox proportional hazards modeling for multivariable analysis. Maximally selected rank statistics determined the cut point for closest surgical resection margin based on LC.RESULTS: Data for 278 eligible patients were analyzed, with median follow-up of 38.5months. Two-year and 5-year outcomes were 69.0% and 62.2% for LC, 71.8% and 49.8% for OS, 47.2% and 35.7% for disease-free survival, and 78.7% and 59.1% for disease-specific survivals. The most discriminating margin cut point was 1.0mm; the 2-year LC was 80.9% above and 54.2% below or equal to 1.0mm. Increasing age, current smoking, primary tumor classification, and narrow surgical margins (≤1.0mm) were statistically significantly associated with lower OS. Hemorrhage with return to theater was seen in 8.1% (n=22 of 272), and 30-day mortality was 1.8% (n=5 of 272). At 1 year, 10.8% (n=21 of 195) used tracheostomies, 33.8% (n=66 of 195) used gastrostomies, and 66.3% (n=53 of 80) had maintained or improved normalcy of diet scores.CONCLUSIONS: Data from international centers show TORS to treat head and neck cancers in previously irradiated fields yields favorable outcomes for LC and survival. Where feasible, TORS should be considered the preferred surgical treatment in the salvage setting.

    View details for DOI 10.1093/jnci/djac130

    View details for PubMedID 35944904

  • Practice patterns in transoral robotic surgery: results of an American head and neck society survey. Journal of robotic surgery Holcomb, A. J., Kammer, R., Holman, A., Goldsmith, T., Divi, V., Starmer, H. M., Zenga, J., Li, R., Patel, U. A., Richmon, J. D. 2022


    To understand perioperative practices for transoral robotic surgery (TORS) among academic medical centers. An electronic cross-sectional survey was distributed to fellows and program directors participating in 49 American Head and Neck Society fellowships. Operative decisions, medical and swallowing management, and disposition planning were assessed. Thirty-eight responses were collected (77.6%). Twenty-three centers (60.5%) performed>25 cases annually with the remainder performing fewer. The da Vinci Si was the most commonly used platform (n=28, 73.7%). A majority of institutions advocated tailored resection to adequate margins (n=27, 71.1%) over fixed subunit-based resection (n=11, 28.9%). Most surgeons (n=29, 76.3%) performed neck dissection concurrent with TORS, and 89.5% (n=34) routinely ligated external carotid artery branches. A minority of institutions (n=17, 45.9%) endorsed a standardized TORS care pathway. Antibiotic choices and duration varied, the most common choice being ampicillin/sulbactam (n=21, 55.3%), and the most common duration being 24h or less (n=22, 57.9%). Multimodal analgesia was used at 36 centers (94.7%), steroids at 31 centers (81.6%), and pharmacologic venous thromboembolic prophylaxis at 29 centers (76.3%). Nasogastric feeding tubes were placed during surgery at 20 institutions (54.1%). Speech-language pathologists routinely performed postoperative swallow evaluations at 29 (78.4%) sites. Practice patterns are variable among institutions performing TORS. While certain surgical and postoperative practices were quite common, many institutions reported no standard TORS care pathway. Further understanding of the impact of individual practices on outcomes is necessary to develop evidence-based perioperative protocols for TORS.

    View details for DOI 10.1007/s11701-022-01448-z

    View details for PubMedID 35933632

  • Assessment of Measures of Head and Neck Lymphedema Following Head and Neck Cancer Treatment: A Systematic Review. Lymphatic research and biology Starmer, H., Cherry, M. G., Patterson, J., Young, B., Fleming, J. 2022


    Purpose: Head and neck lymphedema is a common condition following head and neck cancer (HNC) treatment, with substantial functional morbidity. This systematic review aimed to (1) identify tools used to assess head and neck lymphedema in HNC patients and (2) determine their validity and reliability. Methods: Electronic and hand searches of Prospero, MEDLINE, Cochrane Library, and Embase were searched from their inception until April 2021, and hand searches were independently screened by two reviewers. Studies were included if they were available in English and measured lymphedema in adult HNC patients (aged ≥18 years). Data including psychometric characteristics were extracted and synthesized narratively, with the Quality Assessment of Diagnostic Accuracy Studies-2 and the COnsensus-based Standards for the selection of health Measurement INstruments checklists used to assess risk of bias. Results: Thirty-three studies, reporting 38 assessment tools, were included. Assessments included clinician rating scales, symptom inventories, size measures, measures of internal edema, radiographic and ultrasonographic measures, and quality-of-life measures. Of the 38 measures cited, only 11 had any degree of validation and reliability testing. Risk of bias varied among the different assessment tools. Conclusion: While many tools are used in the assessment of head and neck lymphedema, the majority of these tools lack validation and reliability data. Only one tool, the Head and Neck Lymphedema and Fibrosis Symptom Inventory, met criteria for strong quality assessment. Further efforts to establish a core set of metrics for this complex condition are warranted.

    View details for DOI 10.1089/lrb.2021.0100

    View details for PubMedID 35679595

  • 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


    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


    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


    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

    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

  • Assessment, Diagnosis, and Treatment of Dysphagia in Patients Infected With SARS-CoV-2: A Review of the Literature and International Guidelines. American journal of speech-language pathology Vergara, J., Skoretz, S. A., Brodsky, M. B., Miles, A., Langmore, S. E., Wallace, S., Seedat, J., Starmer, H. M., Bolton, L., Clave, P., Freitas, S. V., Bogaardt, H., Matsuo, K., de Souza, C. M., Mourao, L. F. 2020: 1–12


    Purpose Speech-language pathologists are playing a crucial role in the assessment and management of patients infected with severe acute respiratory syndrome coronavirus 2. Our goal was to synthesize peer-reviewed literature and association guidelines from around the world regarding dysphagia assessment and management for this specific population. Method A review of publications available in the PubMed database and official guidelines of international groups was performed on May 23, 2020. The information was synthesized and categorized into three content areas for swallowing: clinical evaluation, instrumental assessment, and rehabilitation. Results Five publications were identified in the PubMed database. Following title, abstract, and full-text review, only three publications met inclusion criteria: two reviews and one narrative report. Additionally, 19 international guidelines were reviewed. To assess swallowing, a modified clinical evaluation was recommended and only following a risk assessment. Instrumental assessments were often considered aerosol generating, especially transnasal procedures such as endoscopy and manometry. For this reason, many associations recommended that these examinations be performed only when essential and with appropriate personal protective equipment. Guidelines recommended that intervention should focus on compensatory strategies, including bolus modification, maneuvers/postural changes, and therapeutic exercises that can be conducted with physical distancing. Respiratory training devices were not recommended during rehabilitation. Conclusions International associations have provided extensive guidance regarding the level of risk related to the management of dysphagia in this population. To date, there are no scientific papers offering disease and/or recovery profiling for patients with dysphagia and coronavirus disease 2019. As a result, research in this area is urgently needed.

    View details for DOI 10.1044/2020_AJSLP-20-00163

    View details for PubMedID 32960646

  • Aspects of the assessment and management of pharyngoesophageal dysphagia. Annals of the New York Academy of Sciences Allen, J., Dewan, K., Herbert, H., Randall, D. R., Starmer, H., Stein, E. 2020


    Swallowing complaints are common and may have significant consequences for nutrition and pulmonary health. Etiology varies and different aspects of the deglutitive system may be affected. A thorough assessment from the oral cavity to the stomach will provide physiologic information that enables specific targeted management plans to be devised. Although the swallow trajectory bridges anatomic areas, there has previously been a tendency to compartmentalize assessment and treatment by arbitrary anatomic boundaries. It is now clear that this approach fails to appreciate the complexity of swallow mechanics and that systems (oral, pharyngeal, esophageal, and pulmonary) are intertwined and codependent. Swallowing specialists from different backgrounds and with complementary skill sets form a multidisciplinary team that can provide insight and address multiple areas of management. With the advent of new tools for instrumental evaluation, such as manometry, targeted rehabilitative strategies can be informed by physiology, increased in precision and breadth, and assessed quantitatively. Surgical approaches have evolved toward endoscopic techniques, and food technology is expanding options in dietary management. The multidisciplinary team is core to managing this varied and often neglected patient population. This review is for clinicians treating swallowing disorders and will explore the selected aspects of the assessment and management of pharyngoesophageal swallowing disorders.

    View details for DOI 10.1111/nyas.14456

    View details for PubMedID 32794195

  • Patient advocacy in head and neck cancer: realities, challenges and the role of the multi-disciplinary team. Clinical otolaryngology : official journal of ENT-UK ; official journal of Netherlands Society for Oto-Rhino-Laryngology & Cervico-Facial Surgery Dawson, C., Starmer, H., Nund, R., Coffey, M., Roe, J., Govender, R., Brady, G., Patterson, J. M., Topping, A., Nankivell, P., Parmar, S., Sharma, N., Pracy, P. 2020


    This paper explores the concept of advocacy in head and neck cancer. We define inherent challenges in the development and success of advocacy within this context, and offer ways to embed it within clinical practice. We outline what advocacy is, ways in which it may benefit people with head and neck cancer and the engagement required from health care professionals to facilitate advocacy to improve outcomes.

    View details for DOI 10.1111/coa.13508

    View details for PubMedID 31971339

  • Managing the Head and Neck Cancer Patient with Tracheostomy or Laryngectomy During the COVID-19 Pandemic. Head & neck Kligerman, M. P., Vukkadala, N. n., Tsang, R. K., Sunwoo, J. B., Holsinger, F. C., Chan, J. Y., Damrose, E. J., Kearney, A. n., Starmer, H. M. 2020

    View details for DOI 10.1002/hed.26171

    View details for PubMedID 32298035

  • Building an integrated multidisciplinary swallowing disorder clinic: considerations, challenges, and opportunities. Annals of the New York Academy of Sciences Starmer, H. M., Dewan, K. n., Kamal, A. n., Khan, A. n., Maclean, J. n., Randall, D. R. 2020


    Dysphagia is a complex condition with numerous causes, symptoms, and treatments. As such, patients with dysphagia commonly require a multidisciplinary approach to their evaluation and treatment. Integrated multidisciplinary clinics provide an optimal format for a collaborative approach to patient care. In this manuscript, we will discuss considerations for teams looking to build a multidisciplinary dysphagia clinic, including what professionals are typically involved, what patients benefit most from this approach, what tests are most appropriate for which symptoms, financial issues, and traversing interpersonal challenges.

    View details for DOI 10.1111/nyas.14435

    View details for PubMedID 32686095

  • Management of Dysphagia in The Head and Neck Cancer Patient during COVID-19 Pandemic: A Practical Strategy. Head & neck Ku, P. K., Holsinger, F. C., Chan, J. Y., Yeung, Z. C., Chan, B. Y., Tong, M. C., Starmer, H. M. 2020


    The global pandemic of 2019 Novel Coronavirus Disease (COVID-19) has tremendously altered routine medical service provision and imposed unprecedented challenges to the healthcare system. This impacts patients with dysphagia complications caused by head and neck cancers. As this pandemic of COVID-19 may last longer than SARS in 2003, a practical workflow for managing dysphagia is crucial to ensure a safe and efficient practice to patients and healthcare personnel. This document provides clinical practice guidelines based on available evidence to date to balance the risks of SARS-CoV-2 exposure with the risks associated with dysphagia. Critical considerations include reserving instrumental assessments for urgent cases only, optimizing the non-instrumental swallowing evaluation, appropriate use of PPE, and use of telehealth when appropriate. Despite significant limitations in clinical service provision during the pandemic of COVID-19, a safe and reasonable dysphagia care pathway can still be implemented with modifications of setup and application of newer technologies. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1002/hed.26224

    View details for PubMedID 32348591

  • Effectiveness of a Home-based Head and Neck Lymphedema Management Program: A Pilot Study. The Laryngoscope Yao, T. n., Beadle, B. n., Holsinger, C. F., Starmer, H. M. 2020


    This study aimed to compare outcomes in patients with head and neck lymphedema receiving either a home-based lymphedema treatment program or a hybrid approach including both home-based treatment and regular clinical visits.Outcomes were assessed in patients receiving head and neck lymphedema rehabilitation. Baseline measures of neck, submental, and facial edema were obtained and repeated following treatment. A home program was recommended for all patients, and those receiving hybrid care received the same recommendations as well as a visit with the lymphedema therapist for additional treatment. Their outcomes were compared using standard statistical analysis.Fifty consecutive individuals were included, 25 in each group. Adherence to at least 50% of recommended treatment was reported in 68% of those receiving home-based treatment and 84% of those receiving hybrid care. Significant improvement was demonstrated for 66% of patients. There was no statistically significant difference between treatment groups with regard to clinically significant improvement (P = .15). Patients receiving hybrid therapy demonstrated treatment advantages regarding facial edema (P = .037). Adherence to treatment was associated with clinical improvement (P = .047).Comparable benefits were observed regardless of whether patients had a home-based or hybrid lymphedema treatment approach. These data suggest a home-based treatment approach may be appropriate for patients unable to participate in clinical sessions. However, for patients with significant facial edema, a hybrid approach may be preferable. Adherence was associated with better outcomes. Given these findings, future investigations should consider strategies to improve adherence to optimize the outcomes lymphedema treatment.3b Laryngoscope, 2020.

    View details for DOI 10.1002/lary.28549

    View details for PubMedID 32068894

  • Cost comparison of treatment for oropharyngeal carcinoma LARYNGOSCOPE Tam, K., Orosco, R. K., Colevas, A., Bedi, N., Starmer, H. M., Beadle, B. M., Holsinger, F. 2019; 129 (7): 1604–9

    View details for DOI 10.1002/lary.27544

    View details for Web of Science ID 000471915700026

  • Implementation of a targeted HPV educational program in a population with HIV. World journal of otorhinolaryngology - head and neck surgery Ayoub, N., Sunwoo, J. B., Starmer, H. M. 2019; 5 (2): 105–11


    Patients living with human immunodeficiency virus (PLWH) are at higher risk of developing human papillomavirus (HPV)-associated malignancies. This prospective, longitudinal study evaluated the baseline knowledge of PLWH regarding HPV infection and its association with head neck cancer, and it aimed to determine whether a focused educational session could promote both short- and long-term knowledge acquisition in this population. Twenty-seven subjects participated in an interactive educational session and completed pre-test and immediate and delayed (4-month) post-test questionnaires. When compared to their pre-test answers, subjects demonstrated significant improvements in all 28 questions immediately following education. Knowledge preservation was demonstrated 4 months after initial evaluation, with subjects performing significantly better than their pre-test scores in 24 of the original 28 questions. These results suggest that short, focused, educational programs for PLWH may promote a better understanding of HPV's association with human immunodeficiency virus (HIV) and HPV risk factors, methods of transmission, and prevention.

    View details for DOI 10.1016/j.wjorl.2018.09.006

    View details for PubMedID 31334489

  • Clinical Decision Making with Head and Neck Cancer Patients with Dysphagia. Seminars in speech and language Starmer, H. n., Edwards, J. n. 2019; 40 (3): 213–26


    Dysphagia is a common challenge faced by patients with head and neck cancer. Management of these patients is quite distinct from many other dysphagia etiologies due to the nature of surgical removal of organs critical to swallowing, the ability to provide preventative therapies, and the variable risk for complications related to dysphagia. Thus, clinicians providing care to the head and neck cancer population need to understand these differences when employing clinical decision making. In addition, changes in the demographics of head and neck cancer, related predominantly to the epidemic of oropharyngeal cancer associated with the human papillomavirus, have further transformed both the types of patients and the types of treatments offered. These epidemiologic factors further complicate the decision-making process for clinicians. This article provides a framework for decision making in the surgical and nonsurgical patient with head and neck cancer.

    View details for DOI 10.1055/s-0039-1688979

    View details for PubMedID 31158905

  • A Next-Generation Single-Port Robotic Surgical System for Transoral Robotic Surgery: Results From Prospective Nonrandomized Clinical Trials. JAMA otolaryngology-- head & neck surgery Holsinger, F. C., Magnuson, J. S., Weinstein, G. S., Chan, J. Y., Starmer, H. M., Tsang, R. K., Wong, E. W., Rassekh, C. H., Bedi, N. n., Hong, S. S., Orosco, R. n., O'Malley, B. W., Moore, E. J. 2019


    Transoral endoscopic head and neck surgery now plays an important role in the multidisciplinary management of oropharyngeal carcinoma. Previous generations of robotic surgical systems used a multiport system with a rigid stereo-endoscope and 2 wristed instruments that facilitated transoral robotic surgery.To evaluate a new single-port robotic surgical system in head and neck surgery prospectively through concurrent nonrandomized clinical trials.Two prospective clinical trials were conducted from December 16, 2016, to December 26, 2017, to assess the safety, feasibility, and performance of a flexible single-port robotic surgical system in 4 institutions, including 3 in the United States and 1 in Hong Kong. A total of 47 patients with tumors of the oropharynx were enrolled and underwent surgery. All patients were classified as having American Society of Anesthesiologists class I to III status and Eastern Cooperative Oncology Group status 0 to 1. An initial cohort of 7 patients underwent staging and endoscopic procedures for benign disease. The remaining 40 patients all had malignant tumors of the oropharynx.Safety was measured by the incidence of device-related serious adverse events. Feasibility and performance were measured by the conversion rate from the use of the single-port robotic surgical system to either open surgery or the use of any other transoral technology required to complete the planned procedure. Secondary end points of swallowing function and surgical margins were also measured.All 47 patients (8 women and 39 men; mean [SD] age, 61 [8] years) safely underwent transoral resection with the single-port robotic surgical system without conversion to open surgery, laser surgery, or multiport robotic surgery. There were no intraoperative complications or device-related serious adverse events. Mean (SD) estimated intraoperative blood loss per procedure was 15.4 (23.9) mL; no patients received a transfusion. Two patients underwent a planned tracheotomy owing to medical comorbidity (previous chemoradiotherapy; obesity and severe sleep apnea). Two patients (4%) had grade III or IV postoperative hemorrhage, requiring a return to the operating room; however, both patients had medical comorbidities requiring the use of antithrombotic medication. The incidence of positive margins for patients with oropharyngeal malignancy was 3% (1 of 40). Within 30 days, 45 patients (96%) were eating by mouth and without the need for a percutaneous endoscopic gastrostomy tube.This study describes the results of phase 2 clinical testing of a next-generation, robotic surgical system using a single-port architecture. The use of the device appears to be feasible, safe, and effective for transoral robotic surgery of oropharyngeal identifiers: NCT03010813 and NCT03049280.

    View details for DOI 10.1001/jamaoto.2019.2654

    View details for PubMedID 31536129

  • Cost comparison of treatment for oropharyngeal carcinoma. The Laryngoscope Tam, K., Orosco, R. K., Dimitrios Colevas, A., Bedi, N., Starmer, H. M., Beadle, B. M., Christopher Holsinger, F. 2018


    OBJECTIVES/HYPOTHESIS: Based on current guidelines, surgical and nonsurgical therapies are viable frontline treatment for patients with locoregional oropharyngeal carcinoma (OPC). We sought to compare financial parameters between chemoradiation and transoral robotic surgery (TORS) in this patient population.STUDY DESIGN: Case-control study.METHODS: In this study we identified patients with selected American Joint Committee on Cancer 7th Edition stage II to IVa OPC treated with TORS between January 2013 and December 2014. Fifteen patients who underwent TORS were stage matched with 15 patients treated with chemoradiation. Total charges and cost data for each patient were analyzed at 4-month and 1-year time points; functional and oncologic outcomes were assessed.RESULTS: There were no significant differences in functional and oncologic outcomes. Patients undergoing TORS had a longer inpatient hospital stay, and most required a nasogastric tube for an average of 3.5 days. There were no local or regional recurrences. Across all time points, the TORS group had lower charges and costs compared to the chemoradiation group, with 14% lower costs at 1 year. In the chemoradiation group, nearly two-thirds of costs came from radiation therapy and pharmacy expenses. Chemotherapy accounted for most pharmacy costs. The costs of operating the surgical robot accounted for a about half of surgical costs.CONCLUSIONS: Selected patients with stage II to IVa oropharyngeal carcinoma treated with TORS may incur lower costs than those treated nonsurgically. With rising healthcare spending, the financial impact of treatment might be considered for those patients eligible for treatment regimens with comparable functional and oncologic outcomes.LEVEL OF EVIDENCE: 3b Laryngoscope, 2018.

    View details for PubMedID 30485445

  • The impact of developing a speech and swallow rehab program: Improving patient satisfaction and multidisciplinary care. Laryngoscope Starmer, H. M., Ayoub, N., Byward, C., Kizner, J., Le, Q., Hara, W., Holsinger, F. C. 2017


    The objective of this study was to evaluate the impact of developing an integrated head and neck cancer speech and swallowing rehabilitation program on physician/team focus on functional outcomes.Prospective cross-sectional design.Surveys regarding physician behavior and patient satisfaction with speech and swallowing were administered in an academic oncology practice prior to and 1 year following establishment of a dedicated head and neck speech and swallowing rehabilitation program. Participants included new and established head and neck cancer patients recruited consecutively. The primary outcome was physician behavior regarding speech and swallowing outcomes (as measured by discussion of function, providing suggestions regarding function, and referral to speech-language pathology services).A total of 199 surveys were returned at the first time point and 271 at the second. Demographic variables were comparable between the two groups. The later cohort was more likely to report team discussion and suggestions regarding speech and swallowing function than the former (P < .001, 95% confidence interval [CI]: -0.775 to -0.265; P < .001, 95% CI: -0.928 to -0.035, respectively). Although there was no significant difference between the groups in regard to satisfaction with speech (P = .07), more favorable satisfaction with swallowing was reported by the later cohort (P = .028, 95% CI: -0.531 to -0.029).Integration of speech and swallowing rehabilitation into head and neck cancer programs is associated with increased physician focus on functional outcomes and greater patient satisfaction in regard to swallowing function. We advocate for standard integration of such services into the multidisciplinary head and neck cancer care team.4. Laryngoscope, 2017.

    View details for DOI 10.1002/lary.26695

    View details for PubMedID 28561453

  • One-Year Swallowing Outcomes in Patients Treated with Prophylactic Gabapentin During Radiation-Based Treatment for Oropharyngeal Cancer. Dysphagia Starmer, H. M., Yang, W., Gourin, C. G., Kumar, R., Jones, B., McNutt, T., Cheng, S., Quon, H. 2017


    Recent investigations by our study team have demonstrated patients using gabapentin for pain management during chemoradiotherapy (CRT) do well maintaining swallowing during treatment with less need for narcotic pain medication, PEG dependence, weight loss, and short-term swallowing morbidity. The purpose of this investigation was to characterize the long-term swallowing function of these patients 1-year following treatment. Sequential patients receiving CRT for oropharyngeal cancer and concurrent gabapentin were evaluated 1-year following treatment for swallowing outcomes. Functional Oral Intake Scores (FOIS) were utilized to assess diet level. The MD Anderson Dysphagia Inventory (MDADI) was chosen to evaluate patient perception of swallowing function. Videofluoroscopic swallowing studies were completed approximately 1 year after treatment to assess physiologic outcomes as well as Penetration Aspiration Scores (PAS). Data from 26 consecutive participants were available for analysis. The majority of patients had advanced stage disease (Stage 3-4). No patients had a PEG tube 1-year following treatment, and the mean FOIS score was 6.83. Pharyngeal deficits were infrequent with reduced pharyngeal constriction and prominence/early closure of cricopharyngeus predominating. Mean PAS score was 1.5, indicating that the majority of patients had either no laryngeal penetration/aspiration, or transient penetration that was fully cleared. Mean MDADI score was 85.52, indicating that, in general, patients perceived their swallowing to be minimally impaired. Patients receiving gabapentin pain management as part of a comprehensive dysphagia prevention protocol during CRT have excellent long-term swallowing outcomes as reflected in diet levels, physiologic functioning, and patient-perceived quality of life.

    View details for DOI 10.1007/s00455-017-9783-5

    View details for PubMedID 28204979

  • Dynamic Imaging Grade of Swallowing Toxicity (DIGEST): Scale Development and Validation CANCER Hutcheson, K. A., Barrow, M. P., Barringer, D. A., Knott, J. K., Lin, H. Y., Weber, R. S., Fuller, C. D., Lai, S. Y., Alvarez, C. P., Raut, J., Lazarus, C. L., May, A., Patterson, J., Roe, J. W., Starmer, H. M., Lewin, J. S. 2017; 123 (1): 62-70

    View details for DOI 10.1002/cncr.30283

    View details for Web of Science ID 000394719100009

  • Evaluating Post-Radiotherapy Laryngeal Function with Laryngeal Videostroboscopy in Early Stage Glottic Cancer. Frontiers in oncology Marciscano, A. E., Charu, V. n., Starmer, H. M., Best, S. R., Quon, H. n., Hillel, A. T., Akst, L. M., Kiess, A. P. 2017; 7: 124


    Dysphonia is common among patients with early stage glottic cancer. Laryngeal videostroboscopy (LVS) has not been routinely used to assess post-radiotherapy (RT) voice changes. We hypothesized that LVS would demonstrate improvement in laryngeal function after definitive RT for early-stage glottic cancer.Blinded retrospective review of perceptual voice and stroboscopic parameters for patients with early glottic cancer and controls.High-volume, single-institution academic medical center.Fifteen patients underwent RT for Tis-T2N0M0 glottic cancer and were evaluated with serial LVS exams pre- and post-RT. Stroboscopic assessment included six parameters: vocal fold (VF) vibration, VF mobility, erythema/edema, supraglottic compression, glottic closure, and secretions. Grade, roughness, breathiness, asthenia, strain (GRBAS) voice perceptual scale was graded in tandem with LVS score. Assessments were grouped by time interval from RT: pre-RT, 0-4, 4-12, and >12 months post-RT.60 LVS exams and corresponding GRBAS assessments were reviewed. There were significant improvements in ipsilateral VF motion (P = 0.03) and vibration (P = 0.001) and significant worsening in contralateral VF motion (P < 0.001) and vibration (P = 0.008) at >12 months post-RT. Glottic closure significantly worsened, most prominent >12 months post-RT (P = 0.01). Composite GRBAS scores were significantly improved across all post-RT intervals.LVS proved to be a robust tool for assessing pre- and post-RT laryngeal function. We observed post-RT improvement in ipsilateral VF function, a decline in contralateral VF function, and decreased glottic closure. These results demonstrate that LVS can detect meaningful changes in VF and glottic function and support its use for post-RT evaluation of glottic cancer patients.

    View details for PubMedID 28660173

    View details for PubMedCentralID PMC5467001

  • The Impact of Dysphonic Voices on Healthy Listeners: Listener Reaction Times, Speech Intelligibility, and Listener Comprehension. American journal of speech-language pathology Evitts, P. M., Starmer, H., Teets, K., Montgomery, C., Calhoun, L., Schulze, A., MacKenzie, J., Adams, L. 2016: 1-15


    There is currently minimal information on the impact of dysphonia secondary to phonotrauma on listeners. Considering the high incidence of voice disorders with professional voice users, it is important to understand the impact of a dysphonic voice on their audiences.Ninety-one healthy listeners (39 men, 52 women; mean age = 23.62 years) were presented with speech stimuli from 5 healthy speakers and 5 speakers diagnosed with dysphonia secondary to phonotrauma. Dependent variables included processing speed (reaction time [RT] ratio), speech intelligibility, and listener comprehension. Voice quality ratings were also obtained for all speakers by 3 expert listeners.Statistical results showed significant differences between RT ratio and number of speech intelligibility errors between healthy and dysphonic voices. There was not a significant difference in listener comprehension errors. Multiple regression analyses showed that voice quality ratings from the Consensus Assessment Perceptual Evaluation of Voice (Kempster, Gerratt, Verdolini Abbott, Barkmeier-Kraemer, & Hillman, 2009) were able to predict RT ratio and speech intelligibility but not listener comprehension.Results of the study suggest that although listeners require more time to process and have more intelligibility errors when presented with speech stimuli from speakers with dysphonia secondary to phonotrauma, listener comprehension may not be affected.

    View details for DOI 10.1044/2016_AJSLP-14-0183

    View details for PubMedID 27784031

  • Dynamic Imaging Grade of Swallowing Toxicity (DIGEST): Scale development and validation. Cancer Hutcheson, K. A., Barrow, M. P., Barringer, D. A., Knott, J. K., Lin, H. Y., Weber, R. S., Fuller, C. D., Lai, S. Y., Alvarez, C. P., Raut, J., Lazarus, C. L., May, A., Patterson, J., Roe, J. W., Starmer, H. M., Lewin, J. S. 2016


    The National Cancer Institute's Common Terminology Criteria for Adverse Events (CTCAE) is the universal framework for toxicity reporting in oncology trials. The objective of this study was to develop a CTCAE-compatible modified barium swallow (MBS) grade for the purpose of grading pharyngeal dysphagia as a toxicity endpoint in cooperative-group organ-preservation trials for head and neck cancer (HNC). It was hypothesized that a 5-point, CTCAE-compatible MBS grade (Dynamic Imaging Grade of Swallowing Toxicity [DIGEST]) based on the interaction of pharyngeal residue and laryngeal penetration/aspiration ratings would be feasible and psychometrically sound.A modified Delphi exercise was conducted for content validation, expert consensus, and operationalization of DIGEST criteria. Two blinded raters scored 100 MBSs conducted before or after surgical or nonsurgical organ preservation. Intrarater and interrater reliability was tested with weighted κ values. Criterion validity against oropharyngeal swallow efficiency (OPSE), the Modified Barium Swallow Impairment Profile (MBSImP™©), the MD Anderson Dysphagia Inventory (MDADI), and the Performance Status Scale for Head and Neck Cancer Patients (PSS-HN) was assessed with a 1-way analysis of variance and post hoc pairwise comparisons between DIGEST grades.Intrarater reliability was excellent (weighted κ = 0.82-0.84) with substantial to almost perfect agreement between raters (weighted κ = 0.67-0.81). DIGEST significantly discriminated levels of pharyngeal pathophysiology (MBSImP™©: r = 0.77; P < .0001), swallow efficiency (OPSE: r = -0.56; P < .0001), perceived dysphagia (MDADI: r = -0.41; P < .0001), and oral intake (PSS-HN diet: r = -0.49; P < .0001).With the development of DIGEST, the MBS rating has been adapted to the CTCAE nomenclature of ordinal toxicity grading used in oncology trials. DIGEST offers a psychometrically sound measure for HNC clinical trials and investigations of toxicity profiles, dose responses, and predictive modeling. Cancer 2017;62-70. © 2016 American Cancer Society.

    View details for DOI 10.1002/cncr.30283

    View details for PubMedID 27564246

    View details for PubMedCentralID PMC5161634

  • The Effect of Radiation Dose on Swallowing: Evaluation of Aspiration and Kinematics DYSPHAGIA Starmer, H. M., Quon, H., Kumar, R., Alcorn, S., Murano, E., Jones, B., Humbert, I. 2015; 30 (4): 430-437


    Radiation oncologists have focused on the pharyngeal constrictors as the primary muscles of concern for dysphagia. However, our prior investigations have demonstrated that radiation dose to the geniohyoid rather than the constrictor muscles was more closely related to penetration aspiration scores (PAS). We examined the relationship between (1) radiation dose and swallowing temporal kinematics, and (2) between PAS and swallowing kinematics in these patients. Videofluoroscopic swallowing studies of 41 patients following radiation therapy for oropharyngeal cancer were analyzed for thin liquid boluses. Timing measures included duration of laryngeal vestibule closure (DLVC), duration to maximum hyoid elevation (DTMHE), duration to cricopharyngeal opening (DTCPO), and pharyngeal transit time (PTT). PAS was extracted for each swallow and considered normal if ≤2. As minimum and mean dose to the geniohyoid increased, DTMHE, DTCPO, and PTT increased. Worse PA scores were most strongly correlated with radiation dose received by geniohyoid (r = 0.445, p < 0.0001). Mean DLVC varied according to PAS group (normal PAS mean = 0.67 s, abnormal PAS mean = 0.13 s; p < 0.001). Similarly, DTCPO was significantly different based upon PAS (normal PAS mean = 0.22 s, abnormal PAS mean = 0.37 s, p = 0.016). As PAS increased, DTPCO and PTT increased (r = 0.208, p = 0.04; r = 0.204, p = 0.043). A negative correlation was noted between PAS and DLVC (r = -0.375, p = 0.001). Higher doses of radiation to the geniohyoid muscles are associated with increased severity of dysphagia as measured through both kinematics and PAS. Consideration of dose to the geniohyoid should be considered when planning radiation.

    View details for DOI 10.1007/s00455-015-9618-1

    View details for Web of Science ID 000358190800006

  • Quantifying Labial Strength and Function in Facial Paralysis Effect of Targeted Lip Injection Augmentation JAMA FACIAL PLASTIC SURGERY Starmer, H., Lyford-Pike, S., Ishii, L. E., Byrne, P. A., Boahene, K. D. 2015; 17 (4): 274-278


    Facial muscle weakness from paralysis or muscle dystrophy can significantly affect lip strength and function. Lip muscle weakness may result in articulation difficulties and spillage of food, both of which are socially and functionally disruptive for patients. There are few quantitative data on the effect of facial paralysis on lip strength.To quantify the effect of facial paralysis and muscular dystrophy on lip strength and evaluate the effectiveness of targeted lip injection augmentation.Analysis of patients at the Johns Hopkins Hospital between January 1, 2008, and July 31, 2014, presenting for treatment of lip incompetence due to facial paralysis and facial muscular dystrophy was prospectively undertaken. Patients who had undergone direct surgical lip procedures were excluded.Lip pressure measurements, anterior bolus spillage, and articulation of bilabial sounds before and after treatment were assessed by a single speech pathologist. Lip pressures were measured with the Iowa Oral Performance Instrument.Twenty-two patients with unilateral facial paralysis were evaluated for this study. Three patients with facioscapulohumeral muscular dystrophy were also evaluated. In unilateral facial paralysis, central lip strength was reduced in all patients compared with sex-corrected normative data (mean [SD] central lip strength, 5.5 [2.5] kPa in females and 9.6 [4.6] kPa in males). Compared with the nonparalyzed side, labial strength on the paralyzed sided was reduced by 69%. After injection augmentation of the paralyzed side, labial strength improved across the entire lip. Mean lip strength improved by 0.7-fold in the central lip from 5.60 to 9.30 kPa (P = .009), by 1.4-fold on the paralyzed side from 2.2 to 5.33 kPa (P = .006), and by 0.4-fold on the unaffected side from 7.11 to 9.56 kPa (P = .12). Lip strength in the 3 patients with facioscapulohumeral muscular dystrophy were uniformly reduced across the entire lip and improved by 6- to 7-fold after injection augmentation. All patients were noted by the speech pathologist to have improved articulation of plosive sounds and decreased anterior bolus spillage after the injection.Labial strength is reduced across the lip in patients with unilateral facial paralysis. The Iowa Oral Performance Instrument is an effective tool for measuring labial strength and can be use to evaluate the effectiveness of facial reanimation procedures. Injection augmentation of the lip is a simple and effective means of improving labial strength, bilabial sounds, and anterior spillage in patients with facial paralysis or facial muscular dystrophy.3.

    View details for DOI 10.1001/jamafacial.2015.0477

    View details for Web of Science ID 000358080400008

    View details for PubMedID 26086151

  • Short- and long-term outcomes of laryngeal cancer care in the elderly. The Laryngoscope Gourin, C. G., Starmer, H. M., Herbert, R. J., Frick, K. D., Forastiere, A. A., Eisele, D. W., Quon, H. 2014


    To examine associations between pretreatment variables, short-term and long-term swallowing and airway impairment, and survival in elderly patients treated for laryngeal squamous cell cancer (SCCA).Retrospective analysis of Surveillance, Epidemiology, and End Results-Medicare data.Longitudinal data from 2,370 patients diagnosed with laryngeal SCCA from 2004 to 2007 were evaluated using cross-tabulations, multivariate logistic regression, and survival analysis.Dysphagia (odds ratio [OR] = 1.5 [1.2-1.7]), weight loss (OR = 1.3 [1.1-1.6]), esophageal stricture (OR = 3.8 [2.5-5.9]), airway obstruction (OR = 1.9, [1.6-2.3]), tracheostomy (OR = 1.5 [1.2-1.9]), and pneumonia (OR = 1.8 [1.4-2.2]) increased 1 year after treatment. The odds of airway obstruction, esophageal stricture, and pneumonia increased over subsequent years, with significantly increased risk at 5 years for airway obstruction (OR = 3.3 [1.8-5.8]) and pneumonia (OR = 5.2 [2.5-10.7]). Pretreatment dysphagia, chemoradiation, and salvage surgery were significant predictors of long-term dysphagia, weight loss, tracheostomy, and gastrostomy, with pretreatment dysphagia and salvage surgery also associated with pneumonia. Surgery and postoperative radiation was associated with long-term dysphagia (OR = 1.4 [1.0-1.9]) but reduced odds of long-term pneumonia (OR = 0.7 [0.5-0.9]). Long-term dysphagia, gastrostomy or tracheostomy dependence, weight loss, airway obstruction, and pneumonia were associated with poorer survival, with pneumonia associated with the greatest risk of death at 5 years (hazard ratio = 2.6 [2.4-2.9]).Airway and swallowing impairment is common after laryngeal SCCA treatment in elderly patients, increases over time, and is associated with poorer survival-with pneumonia associated with the highest risk of long-term mortality. Patients with pretreatment dysphagia, initial treatment with chemoradiation, and salvage surgery represent a high-risk group with an increased risk of disability and death.2c. Laryngoscope, 2014.

    View details for DOI 10.1002/lary.25012

    View details for PubMedID 25367258

  • Feasibility of rapid discharge after transoral robotic surgery of the oropharynx. The Laryngoscope Richmon, J. D., Feng, A. L., Yang, W., Starmer, H., Quon, H., Gourin, C. G. 2014; 124 (11): 2518-25


    To investigate the use of an algorithm for rapid discharge after transoral robotic surgery (TORS) and its effect on postoperative complications.Retrospective cohort study.A retrospective analysis of TORS cases from September 2009 to February 2013 was conducted. The effect of patient and tumor characteristics on postoperative length of stay (LOS) and complications were analyzed.A total of 91 patients were included; 79 underwent TORS for malignancy and 12 for a benign process. The mean LOS was 1.51 days (range, 1-5 days) with a median of 1 day. The mean time to initiation of oral diet was 1.26 days (range, 1-7 days) with a median of 1 day. Eleven (12%) patients experienced one or more complications during their postoperative course. Multivariate analysis demonstrated a significant association between patient and procedure variables and postoperative complications. TORS base of tongue reduction for obstructive sleep apnea (OSA) was associated with a significantly greater mean incremental time to initiation of oral diet (1.0 days, 95% confidence interval [CI]: 0.4 to 1.7, P < .001). A significantly greater mean incremental LOS was observed for patients with advanced comorbidity and a delay in initiation of oral diet beyond 24 hours.Rapid initiation of oral diet and rapid discharge home is feasible and not associated with postoperative complications. Similarly, the performance of a concurrent neck dissection does not contribute to LOS or the development of postoperative complications. Patients undergoing TORS for OSA are at greater risk of delay in initiation of oral diet and increased LOS.4 Laryngoscope, 124:2518-2525, 2014.

    View details for DOI 10.1002/lary.24748

    View details for PubMedID 24932480

  • Swallowing outcomes in patients with oropharyngeal cancer undergoing organ-preservation treatment. Head & neck Starmer, H. M., Tippett, D., Webster, K., Quon, H., Jones, B., Hardy, S., Gourin, C. G. 2014; 36 (10): 1392-7


    The purpose of this study was to assess swallowing outcomes in a cohort of patients with oropharyngeal squamous cell carcinoma (SCC) undergoing nonoperative treatment.We conducted a retrospective study of patients who completed videofluoroscopic swallowing studies (VFSS) after nonoperative treatment of oropharyngeal SCC. All patients received intensity-modulated radiation therapy (IMRT) ± chemotherapy. Swallowing abnormalities were recorded and the Penetration Aspiration Scale (PAS) quantified airway infiltration.Posttreatment VFSS (n = 71) occurred at an average of 4.69 months posttreatment. Abnormal PAS was noted in 45% of swallow studies. Swallowing decompensations included reduced pharyngeal constriction (75%), epiglottic tilt (70%), cricopharyngeal opening (42%), and hyoid excursion (42%). The only variable independently associated with abnormal PAS was pretreatment swallowing difficulty (odds ratio [OR] = 4.02; p = .009).This study demonstrates that patients undergoing nonsurgical treatment for oropharyngeal SCC are at risk for posttreatment dysphagia. This suggests a need for dysphagia evaluation/management and refinement of interventions to minimize dysphagia.

    View details for DOI 10.1002/hed.23465

    View details for PubMedID 24038454

  • Effect of Gabapentin on Swallowing During and After Chemoradiation for Oropharyngeal Squamous Cell Cancer DYSPHAGIA Starmer, H. M., Yang, W., Raval, R., Gourin, C. G., Richardson, M., Kumar, R., Jones, B., McNutt, T., Cheng, S., Quon, H. 2014; 29 (3): 396-402


    The aim of this study was to examine the impact of gabapentin (neurontin) on swallowing and feeding tube use during chemoradiation (CRT) for oropharyngeal squamous cell carcinoma (OPSCC), and physiologic swallowing outcomes following completion of treatment. A total of 23 patients treated for OPSCC with concurrent CRT and prophylactically treated for pain using gabapentin were assessed. Historical controls were matched for T stage and primary site of disease. Timing of PEG use and removal were recorded. Video fluoroscopic swallowing studies were completed post-treatment to assess physiologic outcomes as well as penetration-aspiration scores (PAS). Functional oral intake scale (FOIS) scores were determined at the time of swallowing evaluation to assess diet level. Patients treated with gabapentin began using their PEG tubes later (3.7 vs. 2.29 weeks; P = 0.013) and had their PEG tubes removed earlier (7.29 vs. 32.56 weeks; P = 0.039) than the historical controls. A number of physiologic parameters were found to be less impacted in the gabapentin group, including oral bolus control (P = 0.01), epiglottic tilt (P = 0.0007), laryngeal elevation (P = 0.0017), and pharyngeal constriction (P = 0.002). PAS scores were significantly lower in the group treated with gabapentin (1.89 vs. 4; P = 0.0052). Patients receiving gabapentin had more advanced diet levels at the time of the initial swallowing study as evidenced by their FOIS scores (5.4 vs. 3.21; P = 0.0003). We conclude that patients using gabapentin for pain management during CRT appears to do well maintaining swallow function during treatment and have favorable post-treatment physiologic swallowing outcomes. Prospective evaluation is warranted.

    View details for DOI 10.1007/s00455-014-9521-1

    View details for Web of Science ID 000338230500012

    View details for PubMedID 24633355

  • Dysphagia in head and neck cancer: prevention and treatment CURRENT OPINION IN OTOLARYNGOLOGY & HEAD AND NECK SURGERY Starmer, H. M. 2014; 22 (3): 195-200


    Swallowing difficulties are among the most problematic outcomes associated with head and neck cancer (HNCA) and the strategies employed to treat it. With a rising incidence of human papilloma virus-associated HNCA, a larger number of patients are expected to survive their cancer, and therefore will be more susceptible to long-term treatment toxicities. Optimization of long-term swallowing outcomes is an important objective for those working with patients with HNCA.The role of the swallowing therapist in the management of patients with HNCA cannot be overstated. This begins with pretreatment evaluation of swallowing. At the time of initial assessment, education should be provided regarding treatment toxicities and the importance of prophylactic swallowing exercises and oral intake. Recent evidence suggests that maintaining an oral diet and engaging in swallowing exercise during radiation have a positive impact on diet level, swallowing physiology, patient-perceived swallowing-related quality of life, and reduced feeding tube use. Although treatment strategies such as radiation de-intensification and transoral surgical treatments show promise for reducing toxicities, evidence regarding their impact is still being amassed.Maintaining an oral diet and performing prophylactic swallowing exercises are currently the most evidence-based strategies for dysphagia prevention in HNCA.

    View details for DOI 10.1097/MOO.0000000000000044

    View details for Web of Science ID 000335959200005

    View details for PubMedID 24614062

  • Dysphagia, Short-Term Outcomes, and Cost of Care After Anterior Cervical Disc Surgery DYSPHAGIA Starmer, H. M., Riley, L. H., Hillel, A. T., Akst, L. M., Best, S. R., Gourin, C. G. 2014; 29 (1): 68-77


    Dysphonia and dysphagia are common complications of anterior cervical discectomy (ACD). We sought to determine the relationship between dysphagia and in-hospital mortality, complications, speech therapy/dysphagia training, length of hospitalization, and costs associated with ACD. Discharge data from the Nationwide Inpatient Sample for 1,649,871 patients who underwent ACD of fewer than four vertebrae for benign acquired disease between 2001 and 2010 were analyzed using cross-tabulations and multivariate regression modeling. Dysphagia was reported in 32,922 cases (2.0 %). Speech therapy/dysphagia training was reported in less than 0.1 % of all cases and in only 0.2 % of patients with dysphagia. Dysphagia was significantly associated with age ≥65 years (OR = 1.5 [95 % CI 1.4-1.7], P < 0.001), advanced comorbidity (OR = 2.3 [2.0-2.6], P < 0.001), revision surgery (OR = 2.7 [2.3-3.1], P < 0.001), disc prosthesis placement (OR = 1.5 [1.0-2.0], P = 0.029), and vocal cord paralysis (OR = 11.6 [8.3-16.1], P < 0.001). Dysphagia was a significant predictor of aspiration pneumonia (OR = 8.6 [6.7-10.9], P < 0.001), tracheostomy (OR = 2.3 [1.6-3.3], P < 0.001), gastrostomy (OR = 30.9 [25.3-37.8], P < 0.001), and speech therapy/dysphagia training (OR = 32.0 [15.4-66.4], P < 0.001). Aspiration pneumonia was significantly associated with in-hospital mortality (OR = 15.9 [11.0-23.1], P < 0.001). Dysphagia, vocal cord paralysis, and aspiration pneumonia were significant predictors of increased length of hospitalization and hospital-related costs, with aspiration pneumonia having the single largest impact on length of hospitalization and costs. Dysphagia is significantly associated with increased morbidity, length of hospitalization, and hospital-related costs in ACD patients. Despite the known risk of dysphagia in ACD patients and an established role for the speech-language pathologist in dysphagia management, speech-language pathology intervention appears underutilized in this population.

    View details for DOI 10.1007/s00455-013-9482-9

    View details for Web of Science ID 000334125400009

    View details for PubMedID 23943072

  • Attendance in Voice Therapy: Can an Interdisciplinary Care Model Have an Impact? ANNALS OF OTOLOGY RHINOLOGY AND LARYNGOLOGY Starmer, H. M., Liu, Z., Akst, L. M., Gourin, C. 2014; 123 (2): 117-123


    We sought to determine the effect of referral patterns on attendance in voice therapy.Patients who were seen by a laryngologist for vocal concerns and referred for voice therapy comprised the study population. Outcomes were compared between those who were initially evaluated through the interdisciplinary voice clinic (IDC), which combined speech-language pathology and laryngology care, and those who were evaluated by a laryngologist alone. Adherence was measured by completion of the plan of care.There were 79 patients evaluated through the IDC and 100 patients evaluated initially by a laryngologist. Patients evaluated through the IDC had more visits with the speech-language pathologist (mean, 3.1 versus 1.24; p < 0.0001). Those initially evaluated through the IDC were more likely to complete their plan of care (p = 0.02). Completion of voice therapy was significantly more likely for individuals coded as being of "other" race (odds ratio, 7.98; p = 0.002) and for patients who participated in the IDC (odds ratio, 2.56; p = 0.018). The cause of dysphonia, sex, marital status, insurance status, days from laryngology referral to the initial speech-language pathologist consultation, the initial Voice-Related Quality of Life score, and distance to the clinic were not associated with patient attendance.Patients evaluated in a coordinated IDC should be more likely to attend voice therapy and complete their plan of care, regardless of other factors.

    View details for DOI 10.1177/0003489414523708

    View details for Web of Science ID 000331923600006

    View details for PubMedID 24574467

  • Patient-Perceived Long-Term Communication and Swallow Function Following Cerebellopontine Angle Surgery LARYNGOSCOPE Starmer, H. M., Ward, B. K., Best, S. R., Gourin, C. G., Akst, L. M., Hillel, A., Brem, H., Francis, H. W. 2014; 124 (2): 476-480


    Evaluation of long-term patient-perceived functional outcomes and quality of life (QOL) related to communication and eating with an emphasis on voice, speech production, and swallowing after cerebello-pontine angle (CPA) surgery.Prospective cross-sectional study.The MD Anderson Dysphagia Inventory (MDADI), Voice Handicap Index (VHI), and Facial Clinimetric Evaluation (FaCE) surveys were distributed to patients who underwent CPA surgery between January 2008 and December 2010. Immediate postoperative cranial nerve function extracted from medical records was compared to long-term patient-perceived function and associated QOL.There was a 61% response rate with a mean postoperative period of 31.6 months (range 15-49). The presence of facial palsy in the postoperative period and the corresponding House-Brackmann (H-B) score were the strongest predictors of patient-perceived long-term function and QOL in all three domains (P < .005). Postoperative vagal palsy by comparison was not associated with long-term disturbance of voice or speech function. Postoperative dysphagia had a particularly large association with perceived long-term facial function and related QOL (P < .0005), with a smaller but significant impact on perceived swallow outcome (P < .05). After adjusting for other variables, the postoperative H-B score remained a significant predictor of perceived long-term facial and voice function and related QOL.Patients with severe facial dysfunction following surgery to the CPA are at increased risk for long-term self-reported difficulties with communication and eating, even with improvement of vagal function. Speech and swallow therapy should therefore be provided to these patients whether or not they also have pharyngeal dysphagia or voice disturbance.2b.

    View details for DOI 10.1002/lary.24252

    View details for Web of Science ID 000329929900032

    View details for PubMedID 23775221

  • Radiation dose to the floor of mouth muscles predicts swallowing complications following chemoradiation in oropharyngeal squamous cell carcinoma ORAL ONCOLOGY Kumar, R., Madanikia, S., Starmer, H., Yang, W., Murano, E., Alcorn, S., McNutt, T., Le, Y., Quon, H. 2014; 50 (1): 65-70


    While radiation dose to the larynx and pharyngeal constrictors has been the focus of swallowing complications, the suprahyoid muscles, or floor of mouth (FoM) muscles, are critical for hyoid and laryngeal elevation and effective bolus diversion, preventing penetration and aspiration. We hypothesize that radiation dose to these muscles may be important in the development of dysphagia.We studied 46 patients with OPSCC treated with CRT and who underwent baseline swallowing evaluations and post-treatment videofluoroscopic swallowing studies (VFSS) from 2007 to 2010. Patients with abnormal penetration aspiration scores (PAS>2) served as the study population and patients with normal PAS scores (≤ 2) served as the control cohort. Three suprahyoid muscles and two extrinsic tongue muscles were individually delineated and collectively referred to as the FoM muscles. Radiation dose-volume relationships for these muscles were calculated. Univariate logistic regression analysis was used to determine parameters of significance between patients with normal or abnormal PAS scores. A multivariate regression analysis was subsequently performed to isolate the most statistically critical structures associated with abnormal PAS.Univariate analysis resulted in significance/borderline significance of multiple structures associated with abnormal PAS following irradiation. However, when a multivariate model was applied, only the mean dose to the floor of mouth and minimum dose to the geniohyoid were associated with post-radiation abnormal PAS.The dose and volume delivered to the collective FoM muscles may be associated with an increased risk of laryngeal penetration/aspiration to a greater degree than previously recognized organs at risk.

    View details for DOI 10.1016/j.oraloncology.2013.10.002

    View details for Web of Science ID 000328734600013

    View details for PubMedID 24238851

  • The Use of Low-Osmolar Water-Soluble Contrast in Videofluoroscopic Swallowing Exams DYSPHAGIA Harris, J. A., Bartelt, D., Campion, M., Gayler, B. W., Jones, B., Hayes, A., Haynos, J., Herbick, S., Kling, T., Lingaraj, A., Singer, M., Starmer, H., Smith, C., Webster, K. 2013; 28 (4): 520-527


    The selection of the contrast agent used during fluoroscopic exams is an important clinical decision. The purpose of this article is to document the usage of a nonionic, water-soluble contrast (iohexol) and barium contrast in adult patients undergoing fluoroscopic exams of the pharynx and/or esophagus and provide clinical indications for the use of each. For 1 year, data were collected on the use of iohexol and barium during fluoroscopic exams. The contrast agent used was selected by the speech language pathologist (SLP) or the radiologist based on the exam's indications. A total of 1,978 fluoroscopic exams were completed in the 12-month period of documentation. Of these exams, 60.6 % were completed for medical reasons and 39.4 % for surgical reasons. Fifty-five percent of the exams were performed jointly by a SLP and a radiologist and 45 % were performed by a radiologist alone. Aspiration was present in 22 % of the exams, vestibular penetration occurred in 38 %, extraluminal leakage of contrast was observed in 4.6 %, and both aspiration and leakage were seen in 1 % of the exams. In cases with aspiration, iohexol was used alone in 8 %, iohexol and barium were both used in 45 %, and barium was used alone in 47 %. In cases with extraluminal leakage, iohexol was used alone in 58 %, iohexol and barium were both used in 31 %, and barium was used alone in 11 %. No adverse effects were seen with the use of iohexol. When barium was used in cases of aspiration and extraluminal leakage, the amount of aspirated barium was small and the extraluminal barium in the instances of leakage was small. Iohexol is a useful screening contrast agent and can safely provide information, and its use reduces the risk of aspiration and the chance of leakage of large amounts of barium.

    View details for DOI 10.1007/s00455-013-9462-0

    View details for Web of Science ID 000328217900006

    View details for PubMedID 23529533

  • Is speech language pathologist evaluation necessary in the nonoperative treatment of head and neck cancer? LARYNGOSCOPE Starmer, H. M., Gourin, C. G. 2013; 123 (7): 1571-1572

    View details for DOI 10.1002/lary.23692

    View details for Web of Science ID 000320784300001

    View details for PubMedID 23737324

  • National prevalence and impact of perioperative vagus nerve injury in vestibular schwannoma LARYNGOSCOPE Ward, B. K., Francis, H. W., Best, S. R., Starmer, H. M., Akst, L. M., Gourin, C. G. 2012; 122 (12): 2824-2831


    Lower cranial nerve injury may be an under-reported complication of vestibular schwannoma surgery. This study aims to characterize the prevalence of complications associated with vagus nerve injury following vestibular schwannoma surgery and the impact of these complications on patient care.Retrospective cross-sectional study.Discharge data from the Nationwide Inpatient Sample for 17,281 patients with vestibular schwannoma who underwent surgery in 2003-2008 were analyzed using cross-tabulations and multivariate regression modeling.Dysphagia was reported in 443 cases (2.6%) and unilateral vocal fold paralysis in 115 cases (0.7%). The mean length of hospitalization was 5.3 days (95% confidence interval [CI], 4.9-5.7) and was prolonged in patients with dysphagia (mean, 11.7 days; 95% CI, 8.9-14.4) and in those with unilateral vocal fold paralysis (mean, 12.1 days; 95% CI, 7.3-16.9). Compared to patients without dysphagia, a diagnosis of dysphagia was associated with advanced comorbidity status (37.0% vs. 18.8%), central nervous system complications (39.3% vs. 15.3%), aspiration pneumonia (7.1% vs. 0.4%), and greater likelihood of requiring medical care at another facility or at home after discharge (48.5% vs. 6.6%, P < .001). Tracheostomy (3.4% vs. 0.8%) and gastrostomy tube placement (20.9% vs. 0.5%) were significantly more likely in patients with dysphagia (P < .0001). After adjusting for other variables, dysphagia, aspiration pneumonia, and tracheostomy were significantly associated with increased length of hospitalization and hospital-related costs.Although infrequently reported in this national inpatient sample, vagus nerve injury-related symptoms are associated with significantly increased length of hospitalization and costs of care.

    View details for DOI 10.1002/lary.23605

    View details for Web of Science ID 000312540000036

    View details for PubMedID 22893589

  • The effect of pneumonia on short-term outcomes and cost of care after head and neck cancer surgery LARYNGOSCOPE Semenov, Y. R., Starmer, H. M., Gourin, C. G. 2012; 122 (9): 1994-2004


    The Centers for Medicare and Medicaid Services has threatened to discontinue reimbursements for ventilator-associated pneumonia (VAP) as a preventable "never event." We sought to determine the relationship between pneumonia and in-hospital mortality, complications, length of hospitalization and costs in head and neck cancer (HNCA) surgery.Retrospective cross-sectional study.Discharge data from the Nationwide Inpatient Sample for 93,663 patients who underwent an ablative procedure for a malignant oral cavity, laryngeal, hypopharyngeal, or oropharyngeal neoplasm from 2003 to 2008 were analyzed using cross-tabulations and multivariate regression modeling.VAP was rarely coded. Infectious pneumonia was significantly associated with chronic pulmonary disease (odds ratio [OR], 1.5; P < .001), while aspiration pneumonia was associated with dysphagia (OR, 2.0; P < .001). Pneumonia from any cause was associated with weight loss (OR, 3.3; P < .001), age >80 years (OR, 2.0; P = .007), comorbidity (OR, 2.3; P < .001), and major procedures (OR, 1.6; P < .001), with increased in-hospital mortality for infectious (OR, 2.9; P < .001) and aspiration pneumonia (OR, 5.3; P < .001). Both infectious and aspiration pneumonia were associated with postoperative medical and surgical complications, increased length of hospitalization, and hospital-related costs.Postoperative pneumonia is associated with increased mortality, complications, length of hospitalization, and hospital-related costs in HNCA surgical patients. Variables associated with an increased risk of pneumonia are inherent comorbidities in HNCA and known risk factors for VAP, making this a high-risk group for this never event. Caution must be used in the institution of reforms that threaten to inadequately reimburse the provision of care to this vulnerable population. Aggressive preoperative identification and treatment of underlying pulmonary disease, weight loss, and dysphagia may reduce morbidity and mortality.

    View details for DOI 10.1002/lary.23446

    View details for Web of Science ID 000307962900019

    View details for PubMedID 22777881

  • Risk Factors for Vagal Palsy following Cerebellopontine Angle Surgery OTOLARYNGOLOGY-HEAD AND NECK SURGERY Best, S. R., Starmer, H. M., Agrawal, Y., Ward, B. K., Hillel, A. T., Chien, W. W., Francis, H. W., Tamargo, R. J., Akst, L. M. 2012; 147 (2): 364-368


    Describe the incidence, risk factors, and outcomes of postoperative vagal palsy in patients undergoing surgical excision of cerebellopontine angle (CPA) tumors.Case series with chart review.Academic tertiary care center.One hundred eighty-one consecutive patients undergoing surgical excision of CPA pathology from January 1, 2008, to December 31, 2010, at Johns Hopkins Hospital. Postoperative unilateral vagal palsy was identified by laryngoscopy or videofluoroscopy, and clinical variables were collected from medical records.Postoperative unilateral vagal palsy was identified in 19 of 181 (10%) patients. Vocal fold motion impairment (VFMI) in combination with pharyngeal palsy was more common than VFMI or pharyngeal palsy alone. Those with vagal palsy had a larger mean tumor size (30 mm) than those without vagal palsy (20 mm, P = .0002) and a significantly longer mean hospital stay (9 vs 5 days, P < .0001). Vagal palsy was not associated with tumor pathology, prior treatment (stereotactic radiation or prior surgery), or surgical approach (suboccipital craniotomy vs translabyrinthine approach). Significant rates of aspiration were observed in patients with vagal palsy (67%).Voice and swallowing function can be affected by surgical excision of pathology of the CPA. Tumor size is an independent risk factor for postoperative vagal palsy, which in turn has important consequences for prolonged hospital stay, aspiration, and voice and swallowing impairment.

    View details for DOI 10.1177/0194599812442042

    View details for Web of Science ID 000314273200031

    View details for PubMedID 22447891

  • The relationship between depressive symptoms, quality of life, and swallowing function in head and neck cancer patients 1 year after definitive therapy LARYNGOSCOPE Lin, B. M., Starmer, H. M., Gourin, C. G. 2012; 122 (7): 1518-1525


    To determine the incidence of depression in head and neck cancer (HNCA) patients following definitive treatment and the relationship between depression and head and neck-specific measures of quality of life and function.Prospective cohort analysis.Two hundred forty-six patients were evaluated with the Beck Depression Inventory Fast-Screen (BDI-FS), University of Washington Quality of Life (UW QOL), Voice Handicap Index (VHI), and MD Anderson Dysphagia Inventory (MDADI) questionnaires. Patients with a preexisting diagnosis of depression were excluded.Complete 1-year post-treatment data were available for 46 HNCA patients, with depression identified in nine patients (20%). On multivariate analysis, depression was significantly associated with poorer global UW QOL (β = -40.3, P < .001) and overall MDADI scores (β = -21.8, P = .038), but not with VHI scores, after controlling for other clinical variables including initial treatment modality. BDI-FS scores were significantly correlated with global UW QOL (r = -0.7, P < .001) and overall MDADI scores (r = -0.5, P = .0045), and global UW QOL correlated significantly with overall MDADI scores (r = 0.4, P = .0166). After controlling for clinical variables, MDADI, and VHI scores, only depression was associated with global UW QOL score (β = -30.5, P = .019).There is a high incidence of depressive symptoms in HNCA patients at 1 year following definitive therapy, which is independent of primary treatment modality and is associated with poorer global QOL and MDADI scores. Although depression and swallowing function are highly correlated, depression has a greater effect on QOL than swallowing scores, suggesting that early identification and aggressive treatment of patients with depressive symptoms is warranted to maximize post-treatment QOL.

    View details for DOI 10.1002/lary.23312

    View details for Web of Science ID 000305577400017

    View details for PubMedID 22467530

  • Prevalence, Characteristics, and Management of Swallowing Disorders following Cerebellopontine Angle Surgery 115th AAO-HNSF Annual Meeting and OTO EXPO Starmer, H. M., Best, S. R., Agrawal, Y., Chien, W. W., Hillel, A. T., Francis, H. W., Tamargo, R. J., Akst, L. M. SAGE PUBLICATIONS LTD. 2012: 419–25


    To describe swallowing disorders encountered after cerebellopontine angle surgery and to explore variables associated with increased incidence of postoperative dysphagia.Case series with chart review.Single academic medical institution.Chart review of 181 consecutive patients undergoing surgical excision of cerebellopontine angle pathology from January 2008 to December 2010 at the Johns Hopkins Hospital. Presence and characteristics of dysphagia were determined by review of speech pathologist reports. Other clinical variables were extracted from the electronic medical record, and statistical analyses were applied to determine factors associated with postoperative dysphagia.Immediate postoperative dysphagia was identified in 57 of 181 patients (31%). Oral, oropharyngeal, and pharyngeal deficits accounted for 51%, 37%, and 12% of dysphagic symptoms, respectively. Facial nerve weakness in the immediate postoperative period was noted in 91% of dysphagic subjects compared with 43% of those without. Mean House-Brackmann score for dysphagic individuals was 4 compared with 2 in the nondysphagic group. Diet alterations were required for 65% of dysphagic individuals, and an additional 9% required tube feeding. Common findings during videofluoroscopic swallowing studies were pharyngeal residue, reduced pharyngeal constriction, and anterior bolus loss. Abnormal penetration-aspiration scores (≥3) were found in 59% of those undergoing videofluoroscopic swallow studies.Oral and pharyngeal swallowing deficits are commonly encountered after cerebellopontine angle surgery. Consultation with the speech-language pathologist appears most critical for any individuals demonstrating postoperative cranial nerve dysfunction, particularly for those with evidence of facial nerve weakness. Early consultation may help to manage short- and long-term functional difficulties.

    View details for DOI 10.1177/0194599811429259

    View details for Web of Science ID 000303545100015

    View details for PubMedID 22101096

  • Multidisciplinary Head and Neck Cancer Clinic and Adherence with Speech Pathology LARYNGOSCOPE Starmer, H., Sanguineti, G., Marur, S., Gourin, C. G. 2011; 121 (10): 2131-2135


    To determine the effect of referral patterns on compliance with speech-language pathology (SLP) treatment of voice and swallowing difficulties in patients with head and neck cancer (HNCA).Retrospective cohort study.Patients with newly diagnosed oropharyngeal HNCA referred for pretreatment SLP evaluation comprised the study population. Compliance was measured by participation in SLP therapy during and after head and neck treatment, as well as by the number of missed and completed visits. Outcomes were compared between patients who were initially evaluated through the multidisciplinary clinic and those evaluated outside of the multidisciplinary clinic format.The final study sample included 118 individuals with oropharyngeal tumors. All patients were treated with primary radiotherapy with or without chemotherapy. Patients evaluated initially through the multidisciplinary clinic had more SLP visits than those who did not participate in the multidisciplinary clinic (mean = 1.8 vs. 0.2, P <.0001). Participation in SLP treatment was significantly greater for patients ≥ 60 years of age (odds ratio [OR] = 2.4, P =.032) and for patients who participated in the multidisciplinary clinic (OR = 19.3, P <.0001). Tumor stage, sex, race, marital status, and insurance status were not associated with patient compliance. Multivariate analysis revealed that participation in a multidisciplinary clinic was the only significant variable associated with SLP treatment compliance (OR = 12.9, P <.0001), after controlling for all other variables.Patients evaluated in a multidisciplinary clinic are more likely to comply with SLP treatment recommendations.

    View details for DOI 10.1002/lary.21746

    View details for Web of Science ID 000295228800015

    View details for PubMedID 21826674

  • The Relationship Between Depressive Symptoms and Initial Quality of Life and Function in Head and Neck Cancer LARYNGOSCOPE Chan, J. Y., Lua, L. L., Starmer, H. H., Sun, D. Q., Rosenblatt, E. S., Gourin, C. G. 2011; 121 (6): 1212-1218


    To determine the incidence of depression in head and neck cancer (HNCA) patients and the effect of depression on baseline head- and neck-specific measures of quality of life and function.Prospective cohort analysis.A total of 255 patients were prospectively evaluated using the Beck Depression Inventory Fast-Screen (BDI-FS) survey, University of Washington Quality of Life (UW QOL), Voice Handicap Index (VHI), and MD Anderson Dysphagia Inventory (MDADI) questionnaires. Patients with a preexisting diagnosis of depression were excluded.Complete data were available for 77 patients with HNCA and 53 controls. Depressive symptoms were identified in 9% of controls and 19% of HNCA patients, and were significantly associated with a HNCA diagnosis (OR = 4.1, P = .044). Among patients with HNCA, depression was significantly more common in black patients (OR = 15.8, P = .017). A significant negative correlation was found between BDI-FS score and UW global QOL score (r = -0.4, P = .0019). Depression was significantly associated with poorer UW global QOL (β = -22.46, P = .0004), recreation (β = -13.77, P = .037), speech (β = -24.05, P = .004), and MDADI functional (β = -17.31, P = .009), physical (β = -14.99, P = .032), and emotional (β = -11.60, P = .049) domain scores but not with other UW QOL or VHI domains, after controlling for all other variables.Patients with HNCA have a high incidence of depressive symptoms at diagnosis, which is significantly higher in black patients, and is associated with poorer QOL and MDADI scores. Pretreatment depression may serve as a marker for patients with increased risk of swallowing impairment and reduced QOL who would benefit from targeted intervention.

    View details for DOI 10.1002/lary.21788

    View details for Web of Science ID 000291259900015

    View details for PubMedID 21541945

  • Pretreatment Swallowing Assessment in Head and Neck Cancer Patients LARYNGOSCOPE Starmer, H. H., Gourin, C. G., Lua, L. L., Burkhead, L. 2011; 121 (6): 1208-1211


    To discuss patient variables associated with swallowing dysfunction in head and neck cancer (HNCA) patients prior to intervention.Prospective, multi-institutional cohort study.All patients included had newly diagnosed head and neck malignancies. Patients undergoing instrumental swallowing evaluations prior to oncologic management were included for analysis. Pretreatment Penetration Aspiration Scores (PAS) were analyzed by primary tumor site, tumor stage, and standard demographic variables.The final study sample was comprised of 204 consecutive individuals with newly diagnosed HNCA. Patients with advanced primary tumor (T) stage laryngeal/hypopharyngeal tumors had higher mean PAS scores (5.18) in contrast to early stage larynx/hypopharynx (1.93), advanced stage oral cavity/oropharynx (2.24), and early stage oral cavity/oropharynx (1.54, P < .0001), indicative of poorer function. Age, race, and sex were not associated with PAS scores. Multivariate logistic regression revealed significantly poorer PAS scores in patients with advanced primary tumors (odds ration [OR] = 3.83, 95% confidence interval [CI], 1.84-8.00, P < .0001) and laryngeal/hypopharyngeal primary site disease (OR = 3.04, 95% CI, 1.41-6.54, P = .004), after controlling for all other variables.This series demonstrates that swallowing dysfunction in high-risk patients may be present in the pretreatment state and should be considered when determining candidacy for organ preservation modalities. These data highlight the importance of instrumental swallowing evaluations prior to intervention, particularly for those individuals with advanced stage and/or laryngeal/hypopharyngeal tumors.

    View details for DOI 10.1002/lary.21800

    View details for Web of Science ID 000291259900014

    View details for PubMedID 21484812

  • Does Prosthesis Diameter Matter? The Relationship Between Voice Prosthesis Diameter and Complications Annual Meeting of the American-Academy-of-Otolaryngology-Head-and-Neck-Surgery-Foundation and OTO EXPO Starmer, H. M., Agrawal, N., Koch, W., Richmon, J., Webster, K., Gourin, C. G. SAGE PUBLICATIONS LTD. 2011: 740–46


    To assess the impact of tracheoesophageal voice prosthesis diameter and treatment status on prosthesis-related complications.Historical cohort study.Single academic medical institution.Patients who underwent total laryngectomy (TL) between 1996 and 2008 were divided into 2 subgroups according to prosthesis diameter: 16F (n = 19) and 20/22F (n = 71). Each patient only used 1 diameter of prosthesis. Time to leakage through the prosthesis, number of episodes of leakage around the prosthesis, number of prosthesis dislodgements, and length changes after the first 6 months were chosen as outcomes of interest.Analysis included 90 patients. Analysis of selected complications by prosthesis diameter revealed no significant differences for time to leakage through the prosthesis, number of leaks around the prosthesis, or dislodgement. Larger diameter prosthesis use was associated with a greater number of length changes (P = .008). Multivariable regression analysis did not find any significant association between prosthesis-specific complications and prosthesis diameter when controlling for other variables. Prior radiation was associated with an increased number of size changes (β = 2.0, P = .004) and a decrease in time to leakage through the prosthesis (β = -4.4, P = .048), after controlling for other variables.Prosthesis diameter is not associated with an increased prevalence of certain voice prosthesis complications in laryngectomy patients, regardless of initial treatment modality, whereas prior radiation or chemoradiation is associated with complications. These data suggest that factors affecting tissue health, rather than prosthesis size, may be more responsible for prosthesis complications.

    View details for DOI 10.1177/0194599810395362

    View details for Web of Science ID 000293998600013

    View details for PubMedID 21493364



    To assess volumetric changes of selected organs at risk (OAR) during intensity-modulated radiotherapy (IMRT) for oropharyngeal carcinoma.Twenty-six consecutive patients that were treated with definitive IMRT ± chemotherapy between November 2007 and November 2008 were selected for the present study. As part of an internal quality assurances program, a repeat kilovolt (KV) computed tomography was planned weekly during the 7-week treatment course. On each available scan, a single observer contoured the parotid submandibular, and thyroid glands (PG/SMG/TG), larynx (L), and constrictor, masticatory, and sternocleidomastoid muscles (CM/MM/SCM) as appropriate. The volume at each scan was compared with the one at planning CT in a pair-wise fashion. p values <0.05 after correction for multiple testing were considered significant.A total of 159 scans was obtained during treatment for a total of 185 scans, including the baseline imaging. All OARs showed statistically significant changes over baseline by week 5. At week 7, the PG showed the largest absolute change with an average reduction of ∼10 mL followed by both the SCM and MM (∼-5 mL). The largest (∼-30%) relative change was observed for the salivary glands. L and CM showed a ∼15% increase in volume during treatment.All selected OAR undergo significant volumetric changes during a course of IMRT for oropharyngeal squamous cell carcinoma.

    View details for DOI 10.1016/j.ijrobp.2010.01.071

    View details for Web of Science ID 000290006300024

    View details for PubMedID 21306971

  • Inhaled Triamcinolone With Proton Pump Inhibitor for Treatment of Vocal Process Granulomas: A Series of 67 Granulomas 89th Annual Meeting of the American-Broncho-Esophagological-Association Hillel, A. T., Lin, L., Samlan, R., Starmer, H., Leahy, K., Flint, P. W. ANNALS PUBL CO. 2010: 325–30


    We sought to analyze the outcomes of vocal process granulomas treated with proton pump inhibitors and inhaled triamcinolone acetonide.We reviewed the medical records of patients with a diagnosis of contact granuloma or vocal process granuloma between 1995 and 2008. Data included age, gender, intubation history, reflux history, lesion location, previous treatment methods, treatment course, and recurrence. All patients were treated with daily or twice-daily protein pump inhibitors and inhaled triamcinolone acetonide (300 microg 3 times a day).Sixty-seven granulomas were diagnosed in 54 patients: 13 bilateral and 41 unilateral. Twenty patients, including all 11 women, had a recent history of intubation. Sixty-two granulomas in 50 patients were treated with triamcinolone and a proton pump inhibitor. Of the 57 granulomas that completed treatment, 5 (9%) did not respond (mean follow-up, 50 weeks; range, 30.3 to 78.3 weeks), 13 (22%) partially responded (mean follow-up, 11 weeks; range, 3 to 30 weeks), and 40 (69%) completely responded (mean follow-up, 21 weeks; range, 5.9 to 84.6 weeks). Three cases had recurrence: 2 nonresponders and 1 complete responder. One patient developed oral thrush.In this study, vocal process granulomas occurred more frequently in men, whereas women developed granulomas only after intubation. The anti-inflammatory action of inhaled triamcinolone combined with antireflux proton pump inhibitors successfully treats most vocal process granulomas with low rates of side effects and recurrence.

    View details for Web of Science ID 000277892700009

    View details for PubMedID 20524578

  • Complications That Affect Postlaryngectomy Voice Restoration Primary Surgery vs Salvage Surgery ARCHIVES OF OTOLARYNGOLOGY-HEAD & NECK SURGERY Starmer, H. M., Ishman, S. L., Flint, P. W., Bhatti, N. I., Richmon, J., Koch, W., Webster, K., Tufano, R., Gourin, C. G. 2009; 135 (11): 1165-1169


    To assess the effect of primary treatment on tracheoesophageal voice prosthesis (TEP) complications.Retrospective cohort study.The Johns Hopkins Medical Institutions, Baltimore, Maryland.Patients who underwent total laryngectomy and TEP between January 1, 1998, and December 31, 2008, were divided into 3 subgroups according to primary treatment: surgery (n = 81), radiotherapy (n = 61), and chemoradiotherapy (n = 32).Number of weeks before leakage through the TEP, occurrence of leakage around the TEP, TEP dislodgement, and size changes 6 months or longer after laryngectomy.A total of 174 patients met the study criteria. Of the 81 patients who underwent primary surgery, 81% (n = 66) underwent adjuvant therapy with postoperative radiotherapy or chemoradiotherapy. The incidence of leakage around the prosthesis, prosthesis dislodgement, and size changes 6 months or longer after laryngectomy were significantly higher for patients who required salvage total laryngectomy after chemoradiotherapy or radiotherapy (P < .05). In addition, significantly more patients who underwent salvage total laryngectomy required extended laryngectomy or free tissue reconstruction.Voice prosthesis complications are more frequently encountered in those who require salvage laryngectomy. Understanding the potential for such complications reinforces the need for close communication and follow-up with these patients by the speech language pathologist.

    View details for Web of Science ID 000271860900019

    View details for PubMedID 19917932

  • Effects of laryngeal cancer on voice and swallowing OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA Starmer, H. M., Tippett, D. C., Webster, K. T. 2008; 41 (4): 793-?


    Specific deficits that may be encountered as well as interventional strategies and evidence-based practice are discussed. When discussing the voice, it is important to consider that for many people the voice is not just a tool for communication, but also an identifying feature that allows expression of personality. Eating and swallowing are vital to life sustenance and also allow for a myriad of social interactions. Laryngeal cancer can have a dramatic impact on this delicately balanced system leading to disturbances of voice and swallowing.

    View details for DOI 10.1016/j.otc.2008.01.018

    View details for Web of Science ID 000257792700011

    View details for PubMedID 18570960