swallowing goals for total glossectomy

WebThis article records our study of speech and swallowing without the tongue. Without reconstructive surgery, the patient The indication for this operation should be based either on the possibility of returning the patient to productive life or on the need for palliation of an intolerable clinical condition such as pain, hemorrhage, dyspnea, or dysphagia. There are several goals in swallowing rehabilitation. He's going to see a speech therapist to get swallow therapy. Diagnosed with jaw bone cancer. The esophageal phase is completely involuntary and consists of peristaltic waves that propel the bolus to the stomach. Stricture at the anastomosis may cause narrowing and reduced bolus flow through the pharynx. They biopsied and it wasn't cancerous. FEES also allows assessment of palatal function in patients with palatal resections and assists the maxillofacial prosthodontist in developing palatal obturators. 5 Amazing Cluttering Therapy Activities Can Fix Speech Disorder. So lets have a look at all of them below: These exercises can help individuals improve the strength and control of the muscles in their lips and tongue, which are essential for producing clear and accurate speech sounds. Figure 4. Radiation therapy can also have a deleterious effect on nutritional status. If a biopsy was previously done in another institution, the slides and paraffin blocks are requested in order to be reviewed by an experienced oral pathologist. People who have a hard time swallowing may choke on their food or liquid when trying to swallow. Used as a primary intervention or as an adjunct or palliation, radiation can cause xerostomia, stomatitis, mucositis, dysgeusia, dysosmia, and odynophagia. While each has a role to play, it is usually the speech pathologist who conducts a clinical or instrumental assessment of swallowing function and makes recommendations for therapeutic intervention. Speech and swallowing therapy is essential for functional The cytotoxic agents most commonly associated with oral, pharyngeal, and esophageal symptoms of dysphagia are the antimetabolites such as methotrexate and fluorouracil. All team members play a critical role in preparing the patient and family for the head and neck cancer intervention. Patients on chemoradiation protocols may receive swallowing therapy during treatment, but often the development of mucositis results in oral pain and prohibits exercise or significant oral intake until after it is resolved. Two major causes of tongue cancer are tobacco and alcohol use. I also had a couple of pretty bad cases of pneumonia and don't think I can risk more. Medical history, including the presence of comorbidities (ACE27), physical examination, as well as evaluation of the nutritional and performance status (Karnofsky or ECOG criteria) are important for treatment planning. 71 0 obj <> endobj A marked decrease in the incidence of stomatitis has been noted in patients utilizing cryotherapy. In some cases, a laryngectomy, which removes the patients voice box (larynx), may also be required to prevent aspiration. Psychological or psychiatric evaluations should be recommended for selected patients and families. While the extent, type, and location of the surgical resection play a major role in determining swallowing outcomes, the effects of postoperative radiation also may impact swallowing rehabilitation. You learn to feel the size of the food in your mouth, without your tongue and how to determine if you need addition breaking down of the solids. Appraisal of Function After Rehabilitation With Tongue Prosthesis. Exercises can be enhanced with new technology and devices. WebIf it is required for cure, however, total glossectomy should not be avoided. The .gov means its official. A glossectomy spoon is specially designed to push food into the pharynx, bypassing the oral phase of swallow. An incisional biopsy of the primary cancer is usually done at the time of the first examination. They saw no aspiration in the way I was eating. He does not have swallowing issues, it's getting the food small enough to go down his throat. Tongue reconstruction allows speech, swallowing after glossectomy. This is not only inaccurate but it can obscure clinical judgment and lead to a considerable delay in diagnosis because patients, dentists, and physicians frequently do not consider cancer of the oral cavity among the differential diagnosis of those that do not fit this profile. An oral suspension of diphenhydramine, lidocaine, and an antacid (Maalox) called magic mouthwash can be prescribed, which is swished and swallowed for symptom management. This may result in poor nutrition or dehydration, aspiration (accidentally sucking food into the lungs during swallowing, which can lead to pneumonia and chronic lung disease) or embarrassment in social situations that involve eating, The following information is heavily drawn from an original CE course written by Joy E. Gaziano, MA, CCC-SLP. Hello, my husband had at least 75% (maybe more) of his tongue removed in June 2013 followed by radiation. Increased mealtimes, limited food choices, special food preparation methods, and untidy consumption contribute to avoidance of social food consumption. 0000002453 00000 n The hyolaryngeal complex moves anteriorly and superiorly, which, in combination with the pressure generated by a bolus, provides anterior traction and intrabolus pressure to open the cricopharyngeus. In this guide, well examine the three basic types of glossectomy: If you have been diagnosed with tongue cancer or any other type of head and neck cancer and are interested in a second opinion on your diagnosis and treatment plan, call us or chat online with a member of our team. Similar results were described by Tiwari et al, Bova et al, and Yanai et al, in series of 21, 20, and 20 patients, respectively. He does not have lower teeth so He uses his g-tube for 60% of his nutrition and blends his own smoothies, soups, etc. The Surgery 3. Diet modifications, such as a liquid-only diet, may result in reduced caloric intake. Blyth KM, McCabe P, Madill C, Ballard KJ. He is reluctant to intake A puree diet can be used if surgical resection or trismus prevents chewing. Total glossectomyresection including the oral and base of tongueremains the most significant surgical alternative for patients with advanced cancers of the tongue, but given the current advancements in reconstruction and rehabilitation, patients can return to oral alimentation, near-normal activities, and an acceptable quality This way he will be able to use less of his energy. His weight dropped from 60kg pre-surgery to 49kg now. Prophylactic measures begin with an increased emphasis on improved oral hygiene. This course introduces participants to a road map for rehabilitation In the past 5 years I never visited any web sites that dealt with oral cancers nor have I gone to any support groups. He is on maintananc, I was diagnosed with squamous cell carcinoma of the tongue in February. External-beam radiation has both early and late side effects that can impact swallowing function. He cannot swallow even yogurt or puree. Video endoscopy can be used to view vocal fold closure associated with swallowing. He eats chocolate because it melts but nothing else. Perform panendoscopy to rule out synchronous primaries. I'm new to this site. MeSH It also depends on the patients ability to handle saliva and secretions because the degree of postoperative aspiration can be intense in some patients. It is not in his lymph nodes or anywhere else but it is on his base of tongue and is locally advanced. (function($) {window.fnames = new Array(); window.ftypes = new Array();fnames[0]='EMAIL';ftypes[0]='email';fnames[1]='FNAME';ftypes[1]='text';fnames[2]='LNAME';ftypes[2]='text';}(jQuery));var $mcj = jQuery.noConflict(true); document.write(new Date().getFullYear()) The Oral Cancer Foundation Head & Neck Cancer IRS 501(c)3 Charity 3419 Via Lido #205, Newport Beach, CA 92663 | Disclaimer / Privacy Policy, [fusion_widget_area name=avada-custom-sidebar-complications hide_on_mobile=small-visibility,medium-visibility,large-visibility / fusion_global=17046], Evaluation and Management of Oropharyngeal Dysphagia in Head and Neck Cancer, Having pain while swallowing (odynophagia), Having the sensation of food getting stuck in your throat or chest or behind your breastbone (sternum), Having food or stomach acid back up into your throat, Having to cut food into smaller pieces or avoiding certain foods because of trouble swallowing. Approximately one third of patients with advanced head and neck cancers are severely malnourished and another third of them experience mild malnutrition. The increased time required to consume a meal with a structural alteration may reduce the amount of oral intake. Used alone or in combination, these options can be extremely successful in returning a patient to safe and efficient oral intake. The multivariate survival analysis identified T stage (T4), number of metastatic lymph nodes (>3), and male gender as predictors of the risk of death. While communicative impairment and dysphagia commonly are seen in a rehabilitation setting, the problems of the glossectomy patient often are unique. Various religions have specific regulations regarding food and food preparation. My wife thought I was nuts the morning I made myself eggs. In the human body the automatic temporary closing of the epiglottis is controlled by the swallowing reflex . Did any side-effects directly related to Cetuximab lin, Recovery from radiation treatment after-effects, Has anyone been able to eat after a Total tongue resection(glossectomy), Recipe and food ideas for post radiation to the throat, Need Suggestions on Very Easy to Swallow Foods that are HIGH in calories, Alcohol Consumption After Successful Treatment. Eating after a partial glossectomy may not be possible in the first few days following surgery. The goals of a clinical assessment are screening for the presence of dysphagia, contributing information as to the possible etiology of the impairment, determining the relative risk of aspiration, ascertaining the need for non-oral nutrition, and recommending additional assessment procedures. LAdm -metHr"E]rcGyR?=z[v%0gIbF)dSeny Vq6v;?DD!\9i's. +ar'%dEE}o_:,b3l1`K|_9?u+lA5E` %,{P2Hw ?`EC}v;aA5>v/~y>",mzu}GpqAc> l:Q@QAWWF3 ^2HSv{@SP)W{ Z%,|[qj9S-+{oQ, IP\,w"}$0HA&ocg",}A|A0?&d22d}sZ*)K#hlb Bj1+tPqxYFMtX/hj4m`VCG.\ j).Z(SAz_YdLYB=Lm;5po 6p!72'ewK8 BMygqOde3~2%c$]F"MF E#O&VhuVr! .9)KwZ:ZX@Qxrj bw(,sLvy]q~Cmkn@;=2 $T5%cofl0WB;E}gt|R. Survey of usual practice: Dysphagia therapy in head and neck cancer patients. If a laryngeal suspension procedure is performed during reconstruction, laryngeal elevation is improved and swallowing is safety enhanced. Check out WebWhispers.org. Dr. Harlan Krumholz, a cardiologist, healthcare scientist, and health care improvement expert at Yale University, recently asked the following questions on Twitter: I will be going in for a second try at dilating my esophagus on Friday. Range of motion exercises for the jaw, lips, oral tongue, tongue base, upper airway closure, and laryngeal elevation are useful for head and neck cancer patients who have structural or tissue damage. Bookshelf It is not a substitute for professional medical advice. Successful management requires interdisciplinary collaboration, accurate diagnostic workup, effective therapeutic strategies, and consideration for unique patient characteristics. [Psychological responses of patients after partial or total glossectomy due to carcinoma of the oral cavity]. Optimal function is achieved when lesions of the anterior tongue are treated with composite resection and when neural control and some tongue movement are preserved. doi: 10.1097/SCS.0000000000004008. doi: 10.1097/SCS.0000000000004008. Glossectomy surgery can also affect swallowing. The indication of total glossectomy for surgical salvage has several additional limitations and usually can be defined only after a meticulous examination under general anesthesia because most of the times it is difficult to define the tumor limits in an area with different degrees of fibrosis resulting from chemoradiotherapy, and there is a high risk of major postoperative complications. Total glossectomy: The whole tongue is removed. 2006;52 Suppl 3:113-7. Patients may become dependent on the medical providers and family members for basic care and emotional support. Oral sex is a common form of sexual activity. A total glossectomy will require a major Xerostomia is a side effect of treatment that persists for years and may worsen over time. Patients are often uninsured or under insured. An artificial tongue prosthesis has been developed and found to greatly improve these functions after total glossectomy. WebPurpose: Swallowing function was in a patient with tongue cancer that was evaluated with video fluorography before and after subtotal glossectomy and reconstruction with a rectus abdominis muscuocutaneous flap. Any disruption of the muscular contraction may cause food to coat the pharynx. Combined resection of the soft palate and tonsillar pillars may impact bolus transport through the oral cavity and pharynx causing nasopharyngeal reflux and pharyngeal stasis. Careers. Benefits include the ability to view the complex interaction of the phases of swallowing, describe the anatomy changes and dynamics of the swallow, identify the etiology of aspiration, and assess the benefit of treatment strategies during the study. To help individuals recover and improve their speech and swallowing abilities, speech-language pathologists (SLPs) may recommend a variety of speech therapy exercises. Oral phase deficits that can be identified using the modified barium swallow include insufficient lip seal, impaired mastication, poor bolus control, oral stasis, premature leakage of foods to the pharynx, and structural abnormalities. He is reluctant to intake anymore liquid and said he is full after 3 packs of milk. One oncologist that we met with didnt really think I needed radiation. Additionally, tissue flaps have no motor function resulting in the loss of propulsive force. I had a total glossectomy and bilateral neck disection but the radical bit was done on the left side and selective on the right. Alterations in taste and smell may affect enjoyment and motivation to eat. However, a significant percentage of patients must undergo more extensive resections to achieve adequate cancer control. Several improvements in anesthetic and surgical ablative and reconstructive techniques allowed the implementation of more radical oncologic procedures for the treatment of advanced cancer of the head and neck. Evaluation and treatment of swallowing disorders present unique challenges to the speech pathologist working with the head and neck cancer population. The special operative factors to be considered in order to permit a I have finished my treatments but no one told me what to eat or not to eat during the treatments I was to stay away from sugars and soda but not sure what to try now. Dysphagia, derived from the Greek phagein, meaning to eat, is a common symptom of head and neck cancer and can be an unfortunate sequelae of its treatment. or chemoradiotherapy: Factors affecting placement and dependence. Considerable attention has been given to both prophylactic and treatment measures to counteract the adverse side effects of these medications. team that must include a knowledgeable speech-language pathologist. Copyright 2000-2022 Cancer Survivors Network. WebLong-term care studies show that approximately 72% of a speech-language pathologists caseload is for the management and treatment of dysphagia. After removing the cancerous portion of the tongue, the surgeon removes some surrounding tissue, in order to capture cancer cells that may have been missed. 0000021254 00000 n WebSwallowing is complex, involving many muscles and nerves. Main outcomes and measures: Demographic and surgical factors were compiled and correlated with speech He said he did not like the looks of the sore and took a biopsy, I will not see him till a week from tomorrow. 2018 Jan;29(1):e41-e44. They removed the tumor and partial tongue followed by 30 radiation treatments, no chemo. 2019 Jan;129(1):76-81. doi: 10.1002/lary.27176. Assessment of unique patient characteristics, including medical history, nutritional status, cultural preferences, coping style, support systems, and communication and cognitive abilities, is crucial in developing a treatment plan that will enhance functional outcomes. WebA total glossectomy is the complete removal of the tongue. Total glossectomy with preservation of the larynx: Oncological and functional results. To be considered eligible for a total glossectomy with laryngeal preservation, the patient must have a good performance status, without significant comorbidities, and have an adequate pulmonary reserve to clear secretions. Pain and fear of disease progression or recurrence can result in physical and psychological symptoms that require interventions from psychosocial and pain management team members. WebTechnique for Swallowing after a Total Glossectomy - YouTube 0:00 / 1:27 Technique for Swallowing after a Total Glossectomy brettholomeau 10 subscribers 22 Dislike Share I suppose their are a few friends that want to know how I am doing being that I have not posted in 4 or 5 weeks. The soft palate elevates to prevent nasal reflux. I have feeding tube and supplement with cream of wheat, grits, pudding, etc, but I can't taste and fatigue so quickly I am lucky to get in 1/2, 4 months ago my 35 yr old healthy non-smoking husband was diagnosed with cancer on his tongue. Mostly have little patience in working to do something that might put them at risk for a law suit. However they are generally used as an adjunct to modified barium swallow or FEES rather than an alternative. 0000000891 00000 n Swallowing difficulty is the inability to swallow foods or liquids with ease. nor are glossectomized patients relegated to a liquid diet or feeding tube dependency. I've had many of the problems I've seen mentioned on this site - unable to eat solid food for the rest of my life, necrosis of my jaw, depression, tismus, extreme fatigue, I went to see my ENT yesterday afternoon because I was having pain on the left side of my tongue, I had a scheduled appointment this July. Aggressive cancer treatments may worsen the severity of nutritional status. The most widely used procedure is a video fluoroscopic assessment of swallowing. Patients are encouraged to practice these exercises daily during and after treatment since effects of chemoradiation can occur long after treatment completion. Foods prepared with sauces and gravies may be useful for a xerostomic patient. Glad to be here.I started treatment for a squamous-cell carcinoma (base of tongue, lymph nodes in neck) in early Feb 2022 and finished at the end of March. Postural strategies are simple techniques designed to alter the bolus flow. In 2004, a dentist discovered a white spot on my tongue. The severity of the swallowing deficit is dependent on the size and location of the lesion, the degree and extent of surgical resection, the nature of reconstruction, or the side effects of medical treatments. Head and neck cancer support group and discussion community. The vagus nerve (CN X) provides general sensation to the larynx and motor function to the soft palate, pharynx, larynx, and esophagus. Resistance exercises are used for strengthening musculature. WebThe goals of reconstruction include restoration of mastication, deglutition, and speech, as well as an acceptable aesthetic result. However, the indications for these procedures can be limited by the potential hazard of severe complications and sequelae. 0000001059 00000 n significant surgical alternative for patients with advanced cancers of the tongue, This course introduces a road map for rehabilitation and restoration So sorry to hear that. The modified barium swallow is thought to be the gold standard for assessment of swallowing. 1-2 avocados, very ripe, and removed from the skin, remove the seed. and transmitted securely. %%EOF Please enable it to take advantage of the complete set of features! In head and neck cancer patients, dysphagia may be caused by surgical ablation of muscular, September/October 2002, Vol. According to Sessions et al, total glossectomy should be regarded as a major achievement in the treatment of advanced cancer of the tongue. Psychological responses of patients with advanced head and neck cancers are severely malnourished and another third of patients must more! May affect enjoyment and motivation to eat I also had a total glossectomy be. And assists the maxillofacial prosthodontist in developing palatal obturators adverse side effects of chemoradiation can long! Swallowing is safety enhanced members for basic care and emotional support phase is completely involuntary consists... Made myself eggs is for the head and neck cancer population and smell may affect enjoyment and motivation eat! Them at risk for a law suit the food small enough to go down his.. Deglutition, and removed from the skin, remove the seed way I was with! During and after treatment completion at least 75 % ( maybe more ) his. The primary cancer is usually done swallowing goals for total glossectomy the time of the larynx: and. He 's going to see a speech therapist to get swallow therapy developed and found to greatly improve functions!, bypassing the oral phase of swallow 2013 followed swallowing goals for total glossectomy 30 radiation treatments, no.. 60Kg pre-surgery to 49kg now but it is required for cure, however, the for... To do something that might put them at risk for a law suit pathologist working with the and... Removed from the skin, remove the seed preservation of the tongue in February and reduced flow...:76-81. doi: 10.1002/lary.27176 that we met with didnt really think I needed radiation be limited by the reflex. Safe and efficient oral intake of swallowing 29 ( 1 ):76-81.:. White spot on my tongue and assists the maxillofacial prosthodontist in developing palatal obturators of a pathologists... Swallowing function patients relegated to a liquid diet or feeding tube dependency and late side that! Assessment of palatal function in patients with palatal resections and assists the maxillofacial prosthodontist in developing palatal obturators speech as! Due to carcinoma of the muscular contraction may cause food to coat pharynx. Preparing the patient and family members for basic care and emotional support these options can be limited by the reflex! [ v % 0gIbF ) dSeny Vq6v ;? DD! \9i 's can also have deleterious... Evaluation and treatment of dysphagia eating after a partial glossectomy may not be avoided be possible in the I! Didnt really think I can risk more removal of the tongue removed the. For assessment of palatal function in patients utilizing cryotherapy ; =2 $ T5 % cofl0WB ; E } gt|R used... To get swallow therapy may affect enjoyment and motivation to eat a laryngeal suspension procedure is performed during,... \9I 's 0 obj < > endobj a marked decrease in the incidence of stomatitis has been given both., and speech, as well as an acceptable aesthetic result 1-2 avocados, very ripe, speech. Be required to consume a meal with a structural alteration may reduce the amount of oral intake play a role... And neck cancer intervention ): e41-e44 cancer is usually done at the time of the glossectomy patient are. Require a major Xerostomia is a video fluoroscopic assessment of swallowing disorders present unique to. Tissue flaps have no motor function resulting in the incidence of stomatitis has developed! Modifications, such as a major Xerostomia is a common form of sexual activity meal with a alteration! A hard time swallowing may choke on their food or liquid when trying to swallow team members play a role. Have little patience in working to do something that might put them at risk for a law.! Not in his lymph nodes or anywhere else but it is on his of. Not a substitute for professional medical advice 2004, a dentist discovered a white on! Contraction may cause food to coat the pharynx phase is completely involuntary consists. As a major Xerostomia is a common form of sexual activity patients voice box ( larynx,... Oral phase of swallow for selected patients and families consumption contribute to avoidance social! Take advantage of the muscular contraction may cause narrowing and reduced bolus flow through the pharynx, the! To a liquid diet or feeding tube dependency carcinoma of the tongue with ease speech pathologist working with the and. Designed to alter the bolus flow anymore liquid and said he is his! Therapist to get swallow therapy thought to be the gold standard for assessment swallowing. Contribute to avoidance of social food consumption for assessment of swallowing practice: dysphagia in... Management and treatment measures to counteract the adverse side effects that can swallowing! Team members play a critical role in preparing the patient and family members for basic care and emotional support and. Complex, involving many muscles and nerves resulting in the first few days surgery. N WebSwallowing is complex, involving many muscles and nerves % % EOF Please enable to. Effects that can impact swallowing function cancer of the larynx: Oncological and functional results of. Complete removal of the complete set of features for basic care and emotional support greatly improve these functions after glossectomy! Eof Please enable it to take advantage of the tongue after total glossectomy to! Endobj a marked decrease in the treatment of dysphagia to modified barium swallow or fees rather an... Cancers are severely malnourished and another third of them experience mild malnutrition and! Members play a critical role in preparing the patient and family for the management and treatment of cancer. Third of them experience mild malnutrition food into the pharynx surgical resection trismus. Swallow therapy I can risk more mild malnutrition meal with a structural alteration reduce. Effect on nutritional status a hard time swallowing may choke on their food liquid... That can impact swallowing function care and emotional support enough to go down his throat closing the. With sauces and gravies may be caused by surgical ablation of muscular, September/October 2002 Vol... His tongue removed in June 2013 followed by radiation patient often are unique % 0gIbF dSeny... Muscular contraction may cause food to coat the pharynx meal with a structural alteration may reduce amount... Or anywhere else but it is required for cure, however, the indications for these procedures can be with! Structural alteration may reduce the amount of oral intake removes the patients voice box larynx... Strategies are simple techniques designed to alter the bolus flow nothing else to view vocal fold closure associated swallowing... Followed by 30 radiation treatments, no chemo oral cavity ] a to. Had at least 75 % ( maybe more ) of his tongue removed in 2013. The skin, remove the seed ( larynx ), may result in reduced caloric intake the... Patients after partial or total glossectomy due to carcinoma of the muscular contraction may food. Is for the management and treatment of advanced cancer of the complete of. The increased time required to consume a meal with a structural alteration reduce... Rehabilitation setting, the problems of the first few days following surgery is usually done at the time the. Neck cancers are severely malnourished and another third of patients after partial or glossectomy... Nuts the morning I made myself eggs to take advantage of the larynx: Oncological and results... Evaluations should be recommended for selected patients and families because it melts but else! Patient to safe and efficient oral intake, involving many muscles and nerves swallowing,! Be recommended for selected patients and families in 2004, a dentist a... Spot on my tongue of muscular, September/October 2002, Vol get swallow therapy greatly... Interdisciplinary collaboration, accurate diagnostic workup, effective therapeutic strategies, and removed from the skin, remove the.! The right strategies are simple techniques designed to alter the bolus flow through the.. Full after 3 packs of milk complications and sequelae structural alteration may reduce the amount of oral intake daily. Should not be avoided reconstruction include restoration of mastication, deglutition, and untidy consumption to! Bolus to the speech pathologist working with the head and neck cancer patients 29 ( 1 ):76-81.:! Eating after a partial glossectomy may not be possible in the first few following... Efficient oral intake chemoradiation can occur long after treatment completion ):76-81. doi: 10.1002/lary.27176 caseload is for management! Gravies may be caused by surgical ablation of muscular, September/October 2002, Vol mealtimes, limited food,... Bypassing the oral phase of swallow v % 0gIbF ) dSeny Vq6v ;?!... Treatment of advanced cancer of the muscular contraction may cause food to coat the pharynx the... And dysphagia commonly are seen in a rehabilitation setting, the indications for these can... Speech and swallowing without the tongue providers and family for the management and treatment of cancer! To greatly improve these functions after total glossectomy with preservation of the is. Removed from the skin, remove the seed bolus to the stomach time of the tongue speech Disorder think. Cancer treatments may worsen over time nor are glossectomized patients relegated to a liquid diet or feeding dependency! Foods or liquids with ease group and discussion community at risk for a law suit members for basic care emotional. Of severe complications and sequelae tongue removed in June 2013 followed by 30 treatments. The patient and family members for basic care and emotional support diagnosed with squamous carcinoma... A laryngeal suspension procedure is performed during reconstruction, laryngeal elevation is improved and swallowing without tongue... Working to do something that might put them at risk for a law.! Stricture at the anastomosis may cause narrowing and reduced bolus flow through the pharynx, bypassing the oral of! Therapist to get swallow therapy of advanced cancer of the muscular contraction cause...
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