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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
1cc Bolus: Patients vs. Controls
1.6
1.4
1.2
Timing in
Seconds
Bolus arrives in the Vallecula (BV1)
before the onset of swallowing
1
0.8
0.6
0.4
0.2
0
b1 AE startH1BV1 BV2AE
Patient UES opening (Pop) occurs
before arrival of the bolus at the UES
(BP1)
PopBP1 H2 PES
close
max
Swallowing Events
HL maxH3PA maxPCL Em
A
pt average
control ave
20cc Bolus
PopBP1 H2 PES
close
.
HL maxH3PA maxPCL Em
max
mean control
mean patient
Timing in
Seconds
2
In Patients, Bolus Arrives at the Vallecula (BV1) before the
1.8
Onset of Swallowing Gestures. The airway closes (AE close)
1.6
after the arrival of the bolus at the UES (BP1)
1.4
1.2
1
0.8
0.6
0.4
0.2
0
b1 AE startH1BV1 BV2AE
-0.2
Swallow Events
B
Figure 17–8. A. Comparison of patients and controls 1 cc: in patients, the bolus arrives
at the vallecula prior to the onset of swallowing gestures. The pharyngoesophageal
segment (UES) opens before the bolus arrives at the UES (Bp1). This finding may represent a strategy developed by patients to improve movement of the bolus through the
UES compensating for poor pharyngeal pressures behind the bolus. B. Comparison
of patients and controls 20 cc: similar to the 1-cc bolus; when swallowing 20 cc, the
patient allows the bolus to arrive at the vallecula prior to the onset of swallowing gestures. This delay in swallow initiation may represent a change in sensation. There is also
a delay in airway closure relative to arrival of the bolus at the UES. continues
study, therapy could be based on the
most common abnormalities identified
to date: (a) pharyngeal residue (consistent with poor pharyngeal constriction
needed to clear the bolus from the pharynx) and poor tongue base retraction
(an important component of adequate
pharyngeal constriction), (b) reduced
hyoid elevation, and (c) inability to
adjust coordination of swallowing gesture to accommodate larger bolus size.
Although therapy designed to improve
contraction of the pharyngeal constrictors is limited, tongue base exercises
Timing in
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Seconds
C
Timing in
Seconds
17. DYSPHAGIA IN HEAD AND NECK CANCER PATIENTS
Comparison of Control 1 and 20 cc Bolus
1.2
For 20cc, the bolus arrives at the
1
UES much sooner (BP1) so airway
protection happens faster too
0.8
0.6
0.4
0.2
0
b1 AE startH1BV1 BV2AE
-0.2
PopBP1 H2 PES
close
HL maxH3PA maxPCL Em
max
control ave 1cc
control ave 20cc
Swallowing Events
Comparison of Patient 1 and 20cc Bolus
2
1.8
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0
b1 AE startH1BV1 BV2AE
PopBP1 H2 PES
close
HL maxH3PA maxPCL Em
max
pt average 1cc
pt average 20cc
Swallowing Events
415
D
Figure 17–8. continued C. Normal adjustments in gesture timing in response to
increased bolus size: gestures occur earlier to protect the airway. D. Patients are unable
to vary the gesture timing to accommodate the larger bolus size. The airway closes after
arrival of the bolus at the UES for the larger bolus. This may create a risk for aspiration.
may be helpful. Therapy regimens
intending to improve hyoid elevation
have been established to be effective
and can be applied to this patient population as well. Therapy should include
strategies to improve airway protection early in the swallow and should
include work with larger bolus sizes.
Further studies are needed to evaluate
the results of these interventions during
and after treatment.
QUALITY OF LIFE
The lingering effects of head and neck
cancer treatment have an impact on
overall quality of life. Especially when
more than one treatment modality
exists and both provide equal oncologic
outcome, it is important to determine
the impact of each treatment on overall functioning and therefore quality of
life. In the instance of head and neck
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
cancer treatment, surgery followed by
radiation therapy and primary chemoradiation therapy with and without a
neck dissection result in equal overall
prognosis for cure. The impact of these
treatments on swallowing function,
however, determines their effect on
long-term quality of life.
Most studies of quality of life in head
and neck cancer patients have demonstrated a decrease in nearly all parameters of health-related quality of life
during and immediately after chemoradiation treatment, with improvements
beginning around 6 months later, when
the acute effects of therapy are diminishing. Studies looking specifically at
swallowing function, however, note a
deterioration of swallowing function
at 3 months with little improvement
at the 12-month posttreatment point
(Wilson et al., 2011). Long-term qualityof-life studies in head and neck cancer
patients are relatively few but document persistent swallowing dysfunction (Aylward et al., 2019). In a study
of 62 head and neck cancer patients
treated with chemoradiation who had
survived at least 5 years after their
diagnosis, Campbell et al. (2004) found
that 44% of the patients demonstrated
at least some aspiration on a videofluoroscopic swallowing study and 21%
silently aspirated. In this study, aspiration was significantly associated with
diminished quality of life scores for
chewing, swallowing, and normalcy
of diet. Another study of 337 similar
patients revealed that less than half
reported normal or near-normal functioning for eating (Funk et al., 2012).
Kendall et al. (2014) found no strong
correlation between quantitative measures of swallowing function and qual-
ity-of-life scores 1 year after chemoradiation treatment, leading the authors
to conclude that patient perception of
the impact of swallowing function on
quality of life does not correlate well
with actual physiologic functioning.
Clinicians involved in management of
these patients should not rely on patient
reports of function but must perform a
complete evaluation to determine the
specific pathophysiology affecting individual patients.
When quality-of-life studies are conducted comparing patients treated by
laryngectomy and postoperative radiation therapy to patients treated with
chemoradiation for laryngeal cancer,
the results indicate that laryngectomy
patients report diminished satisfaction
in the domains of speech and shoulder
functioning and that chemoradiation
therapy patients report worse satisfaction in the domains of chewing and
swallowing (Lotempio et al., 2005). One
might conclude that patients undergoing total laryngectomy are more
affected by their speech rehabilitation
challenges than by any swallowing
difficulties and that patients treated
with chemoradiation, while maintaining excellent speech capabilities, may
suffer significantly with dysphagia.
Patient treatment options that consider
the location and size of the tumor will
be better defined as further studies
bring to light the potential long-term
effects of each treatment option.
CONCLUSION
The variability inherent in head and
neck cancer patients, with respect to
location and size of the tumor, as well
17. DYSPHAGIA IN HEAD AND NECK CANCER PATIENTS
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417
as treatment modality, creates significant difficulty when categorizing
patients into groups for comparison of
outcome studies involving deglutition.
Each patient must be considered individually. Other factors, including the
overall medical condition, social situation, and support system, will likely
influence the patient’s ability to achieve
adequate safe oral intake and maintain
nutritional requirements.
Our goal, as clinicians, is to optimize the functioning of each individual
patient after first effectively eradicating
the cancer. Surgeons must continue to
consider the structures involved in the
tumor and thoughtfully reconstruct
defects in such a way to minimize
functional deficits and obstruction to
bolus flow. Radiation oncologists must
continue to evaluate strategies for minimizing radiation scatter and determine
the minimal dose required for effective treatment of any given tumor.
Speech-language pathologists must be
involved with the care of these patients
before they begin treatment. Swallowing function must be assessed prior
to treatment, and strategies for safe,
effective swallowing during treatment
must be determined. Swallowing exercises must be initiated and, if possible,
continued during treatment. Patients
should be monitored closely in the posttreatment period and encouraged as
they begin to expand their oral intake.
Patient perceptions of function may not
accurately reflect actual swallowing
abilities.
There is still substantial research to
be done in the area of swallowing function after treatment for head and neck
cancer. In particular, objective data on
the effect of swallowing exercises dur-
ing treatment on long-term swallowing
outcomes are needed. The potential to
improve the long-term swallowing
function, and thus the quality of life,
in head and neck cancer patients is
significant.
STUDY QUESTIONS
1. How does tongue tethering impact
swallowing function? For example,
if the tongue is tethered to the anterior oral cavity (as in primary closure of an anterior floor of mouth
defect), how does that affect the
movement of the bolus through the
pharynx?
2. What are the consequences (for
swallowing) of a palatal defect?
3. What reconstructive options are
available to repair a tongue defect,
and what is the potential impact
of each option on swallowing
function?
4. How does poor hyoid bone elevation impact swallowing function?
5. What pretreatment factors best predict the likelihood of developing
dysphagia after treatment for head
and neck cancer?
6. Discuss the use of nonoral feeding
during chemoradiation therapy.
What are the pros and cons?
7. What structures are removed during an open supraglottic laryngectomy? What are the implications
for swallowing function?
8. What clinical factors increase the
risk of dysphagia after chemoradiation therapy?
9. What treatment factors increase the
risk of developing dysphagia after
chemoradiation therapy?
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
10. What is the incidence of aspiration
in long-term (greater than 5 years)
survivors of head and neck cancer?
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