3 DISCUSSION
Patients with cancer of the head and neck may be
treated with surgery, radiotherapy, chemotherapy, or
a combination. Each treatment modality may have a
negative impact on post-treatment swallowing
function, especially in this case report dysphagia
occurred after treated by radiation. Rehabilitative
management available to reduce or eliminate
swallowing disorder in patients treated for cancer of
the head and neck, which include postures,
maneuvers, exercises, and modalities such as NMES
and sEMG biofeedback to help patient achieve
optimal function, improve swallowing function,
safety oral intake, and enhance QoL (Pauloski,
2008).
In this patient, radiation dose was 40 Gy which
may affect fibrotic in irradiated structures results in
limited mobility of the oral tongue, tongue base,
pharynx and larynx. Besides that, radiation also
damage the salivary glands results in significantly
reduced salivary flow. Patient also felt dry in saliva.
Studies of saliva flow after radiation showed that
reduce the dose with below 24 to 26 Gy made saliva
flow is persevered and will increase toward
pretreatment levels over the first year. Glands
receiving a mean dose higher than the threshold will
produce little saliva with no recovery over time.
Reduced saliva weight does not correlate with
slowed or inefficient swallow. Instead, reduced
saliva weight seems to change the patient’s
perception of swallowing ability and, on that basis,
affects diet choices (Logemann, 2001).
Oromotor exercises that include range of motor
(ROM) exercise, postures, and maneuvers were
given to the patient. The normal range of motion of
the lips, jaw, tongue, and larynx is often disrupted
after treatment for cancer of the head and neck, as a
result of fibrosis induced by radiation. ROM
exercises are designed to improve the movement by
extending the target structure in a desired direction
until a strong stretch is felt. Range of motion
exercises can be used for the lips, jaw, oral tongue,
tongue base, larynx, and hyoid-related musculature
to improve movement. Tongue range of motion
exercises for the oral tongue include extension,
lateralization, elevation, and retraction (Pauloski,
2008).
Mendelsohn maneuver is one of maneuver that
we give to the patient. This maneuver is a voluntary
prolongation of laryngeal excursion at the midpoint
of the swallow, intended to increase the extent and
duration of laryngeal elevation and thereby increase
the duration of cricopharyngeal opening. Since the
first FEES showed that patient had delayed of
laryngeal elevation, we choosed Mendelsohn
maneuver which research has indicated that it is
effective at increasing the extent and duration of
laryngeal elevation as well as duration of
cricopharyngeal opening. Mendelsohn maneuver
may be practiced with or without a bolus as dictated
for safety and as an exercise (Pauloski,2008).
The Masako exercise or tongue-hold exercise is
an oro-pharyngeal exercise rehabilitation technique
to enhance the function of the constrictor pharyngeal
superior. This technique is mainly performed to
strengthen its function of pushing food boluses from
the oral cavity to the pharynx by strengthening the
contact between the tongue base and the laryngo-
pharyngeal wall. Patient holds the tongue forward
between the teeth while swallowing. Its intent is to
improve movement and strength of the posterior
pharyngeal wall during the swallow (Logemann,
2008; Byeon, 2016).
Another exercise that we were given to the
patient is Shaker Exercise. Suprahyoid muscle group
responsible for displacement of the hyolaryngeal
complex and opening of the Upper Esophageal
Spinchter (UES) appears responsive to external
influences, like a simple isometric/isokinetic head
lift exercise. For this exercise, patient was instructed
to raise the head high and forward enough to be able
to see their toes without raising shoulders off the
ground. The rationale for the exercise is to build
strength in the suprahyoid musculature, thus
enhancing hyoid and laryngeal (Pauloski 2008).
sEMG Biofeedback was used to the patient twice
a week for evaluate the exercise. Biofeedback was
used during swallow attempts and oromotor exercise
to assist the patient in maintaining the requested
duration of each swallow attempt and to providing
progressively more challenging targets based on
strength. Electrodes were placed on the on the
submental muscles (mylohyoid, geniohyoid, anterior
belly of digastric, genioglossus) and a third
reference electrode was placed to one side of
zygomaticus. The sEMG signal represents the timing
and force of the muscle contraction and is displayed
graphically on a screen. An ascending threshold
approach was employed in which the patient was
required to progressively increase swallow effort
and strength to obtain a visual feedback (Benfield,
2008; Crary, 2004).
Surface neuromuscular electrical stimulation
(NMES) has recently been proposed as a treatment
option for pharyngeal dysphagia. Surface electrical
stimulation is applied through electrodes placed on
the neck with the goal of promoting increased hyoid