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Dysphagia Evaluation and Treatment After Head and Neck Surgery 467
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Fig. 8 Videoendoscopic laryngeal images of a patient who underwent supracricoid laryngectomy with crico-hyodo-epiglotto-
pexy (CHEP); larynx during respiration (a) and phonation (b)
Fig. 9 Videofluoroscopic imageof aspiration aftersurpacricoid
laryngectomy with crico-hyodo-pexy (CHP); an incomplete
opening of the upper esophageal sphincter is also visible
with extensions of more than 50 % of the hypopharynx
it is advisable toperform a total pharyngectomy.In case
of extension to the esophagus, total laryngopharyngectomy with esophagectomy can be performed; the
most frequently used reconstruction techniques are a
tubed jejunumfree flap,tubed pectoralis major flapand
gastric pull-up (Remacle and Eckel 2010). After TL
there is a significant modification of the aerodigestive
tract, and the respiratory and digestive tracts are
entirely separated: the mouth, pharynx and esophagus
Fig. 10 Videofluoroscopicimage of aspiration aftersurpacricoid
laryngectomywithcrico-hyodo-pexy(CHP)severalyearsafterthe
surgical procedure
act as the digestive system, while the trachea, directly
attached tothe skin of the neck,is the first section of the
respiratory system.
Even if swallowing is usually well preserved and
aspiration is not possible after TL, two-complications
may lead to dysphagia: pharyngeoesophageal stenosis/
stricture and esophageal motility disorders. Pharyngoesophageal stenosis/stricture may occur after large
resections or asa consequence of adjuvant RT (Fig. 12).
Outpatient dilatation is usually effective in restoring
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Fig. 11 Schematic drawing
of total laryngectomy;
incision of the muscle (a);
suture of the pharynx (b).
Taken from Remacle and
Eckel 2010
swallowing, even if the dilatation procedure has to be
repeated over time. In the unlikely situation that dilatation is unsuccessful, flap augmentation (e.g., pectoral
majoror jejunal free flap) may benecessary.Esophageal
motility impairment has been found in patients after TL
(Fig. 13): the amplitudeof contractionsis lower, and the
number of nonperistaltic contractions is higher; besides,
the duration of lower esophageal sphincter relaxation is
shorter and the upper esophageal sphincter pressure is
lower in laryngectomized patients than in control subjects (Dantas et al. 2002;Dantasetal.2005).
2.4 Surgery for Neck Metastasis
Metastasis of head and neck malignancies to the neck
lymph nodes arecommonand appropriate management
of neck metastasis is as important as tumor treatment.
Both surgical and non-surgical options are available;
only surgical options will be considered in this paragraph. Several cervical lymph node dissections are
currently used forthesurgical treatment in patientswith
head and neck cancer. Neck dissections are classified,
taking into account the lymph node groups(submental,
submandibular, jugular, supraclavicular, paratracheal
nodes) that are removed and the anatomic structures
that may be preserved (spinal accessory nerve, sternocleidomastoid muscle). Basedon this assumption, there
are three anatomic types of neck dissections: radical,
selective and extended. In radical neck dissection, en
bloc removal of the lymph node bearing tissue of one
side of the neck, from the inferior border of the mandible to the clavicle, and from the lateral border sternohyoid muscles to the anterior border of the trapezius, is
performed. Included in the resection are the spinal
accessory nerve, the intrajugular vein and the sternocleidomastoid muscle. In selective neck dissection,
only the lymph node groups at highest risk of containing metastases are removed. Extended neck dissections may includelymph nodes that arenot routinely
removed (retropharyngeal,upper mediastinal), or other
structures that are not routinely removed (skin of the
neck, carotid artery, vagus or hypoglossal nerve).
Even if neck dissection is considered not to impair
swallowing, several important muscular and nerve
structures for swallowing may be damaged during
neck dissection, and there is evidence that swallowing
modifications may arise (Hirai et al. 2010). In particular, a lower rest position of the hyoid bone and a
decreased hyoid bone elevation have been described,
together with penetration in a percentage of patients;
no residue or pharyngeal transit time modifications
were found. Recurrent laryngeal nerve injury and
suprahyoid muscle resection are the most likely elements involved in the pathogenesis of swallowing
impairment. Even if dysphagia is unlikely to develop
following neck dissection, there is evidence that using
a feeding tube is prolonged in patients with head and
neck cancers who underwent neck dissections in
addition to tumor treatment (Lango et al. 2010).
3 Chemo-radiotherapy for Head
and Neck Malignancies
Chemo-radiotherapy can be deliveredwithcurativeintent
(radical chemo-radiotherapy), in order to improve
local control following surgery (adjuvant chemo-radiotherapy), orto provide symptomatic relief only(palliative
chemo-radiotherapy). Chemotherapy is administered in
Dysphagia Evaluation and Treatment After Head and Neck Surgery 469
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Fig. 13 Videofluoroscopic image of an hypertone of the upper
esophageal sphincter (arrow) after total laryngectomy
latter improves locoregional control, but also increases
acute toxicities for head and neck cancer patients (Harari
2005). Therole ofchemo-radiotherapy in Head and Neck
cancer treatment increased significantly after the intro-
Fig. 12 Videofluoroscopic image of a mild stenosis (arrow)
after total laryngectomy
duction of intensity-modulated RT (IMRT) (Liu et al.
2010). IMRT is an advanced mode of high-precision RT
that utilizes computer-controlled linear accelerators to
combination with locoregional therapy to improve survival. The chemotherapic agents most widely used are
cysplatinum (100 mg/m
5-Fluoro-Uracil, 5-FU (1 g/m
2
on days 1, 22 and 43) and
2
on days 1 and 4). RT uses
ionizing radiation to treat malignancies. Ionizing radiation may be delivered as an external radiation beam targeting the tumor (external beam RT), or by directly
implanting radioactive sources within the tumor (brachytherapy). External beam RT is usually fractionated,
which means that the total dose is delivered over time in
smaller doses or fractions. The dose of radiation that can
be delivered to a tumor is limited by the tolerance of the
deliver precise radiation doses to a malignant tumor or
specific areas within the tumor. IMRT allows for the
radiation dose to conform more precisely to the threedimensional shape of the tumor by modulating the
intensity ofthe radiation beamin multiplesmall volumes.
IMRT alsoallows higherradiation dosesto befocused on
regions within the tumor while minimizing the dose to
surrounding normal critical structures. Typically, combinations of multiple intensity-modulated fields coming
from different beam directions produce a custom tailored
radiation dose that maximizes the tumor dose while also
minimizing the dose to adjacent normal tissues.
surrounding normal tissues, which are also unavoidably
irradiated during treatment. Generally, the dose of radiation per day is 1.8–2 Gy for 5 days a week for
6–7 weeks for a total of 70 Gy. Altered radiation frac-
3.1 Effects of Chemo-radiotherapy
on Mucosa, Cartilage and Muscles
tionation regimens that incorporate acceleration and/or
hyperfractionation have alsobeen proposed; acceleration
involves a reduction in overall treatment time, while
hyperfractionation involves the use of multiple smaller
dose fractions delivered at an increased frequency. The
Concomitant chemo-radiotherapy protocols for locally
advanced oropharynx carcinoma increases the overall
survival rate but can cause significant and severe swallowing problems secondary to anatomic and functional
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the result of neuromuscular fibrosis and of increased
apoptosis (Smithetal.2000)andplaythemostimportant
role in the genesis of dysphagia.
3.2 Effects of Chemo-radiotherapy
on Swallowing
Chemo-radiotherapy plays a critical role in producing
swallowing disorders in head and neck cancer patients
(Eisbruch et al. 2002). A number of variables
determines the incidence of late complications: total
radiation dose, fraction size, radiated volume, interfraction interval, treatment techniques, use of IMRT
and tissue-dose compensation, and location and size of
the primary tumor (Dornfeld et al. 2007). Even if most
of the widely described impairments occur in the first
Fig. 14 Videofluoroscopic image of a thickened epiglottis after
radiotherapy
changesoccurring in the mucosa, cartilagesandmuscles
that are involved in swallowing. In particular RT may
induce edema, erythema, decreased acuity of taste buds,
decreased production of the salivary glands, and desquamation of the skin that may eventually lead to atrophy and fibrosis of the connective tissues (Fig. 14).
Xerostomia dryness of the mouth may impair normal
oral functions (speech, chewing, and swallowing)
becauseofinsufficient wettinganddecreased lubrication
of the mucosal surfaces and of ingested food. Furthermore, the oral mucosa can become dry and atrophic,
leading to frequent ulceration and injury. Finally, the
shift in oral microflora towards cariogenic bacteria, the
reduced salivary flow (oral clearance), and changes in
saliva composition (decreased buffer capacity, pH, immunoprotein concentrations), may result in rapidly
progressing radiation caries. In addition, concomitant
chemo-radiotherapy affects the neuromuscular mechanism of swallowing resulting in multiple swallowing
measure abnormalities, including increased oro-pharyngeal transit time, uncoordination of bolus movement
through the oropharynx, reduced tongue-base contact
with the posterior pharyngeal wall, restricted laryngeal
and hyoid elevation and movement, poor vestibule and
true vocal fold closure, possibly abnormal upper
esophageal sphincter function and persistentpharyngeal
residue and aspiration. These disorders are most likely
two years after chemo-radiotherapy, a number of
oro-pharyngeal motility disorders can also be found
many years after treatment (Jensen et al. 2007).
DuringRT, and inthefirst weeks afterwards,patients
experience oral mucositis which severely impacts on
oral intake.When oral and pharyngealmucositis heals,a
significant improvement in oral diet is seen and a correlation between healing from oral mucositis and oral
intake is visible (Pauloski et al. 2011); nonetheless,
oro-pharyngeal deficits are still visible. Oral phase
impairment includes reduced mouth opening, reduced
range of lingual motion, reduced lingual strength,
impaired bolus formation, impaired bolus transport
through the oral cavity, prolonged oral transit times and
increased oral residue. As for the pharyngeal phase,
several defects are found: reduced tongue base posterior
movement, defective velopharyngeal closure, delayed
triggering of the swallowing reflex, reduced pharyngeal
contraction, reducedlaryngealelevation, reducedglottis
and laryngeal vestibule closure, and reduced opening of
the upper esophageal sphincter. Impairment is limited
not only to motor function but to sensibility as well;
several authors found reduced laryngeal sensibility,
defective or absent laryngeal adductor reflex and silent
aspiration in patients who underwent RT. Motor and
sensibility impairment lead to reduced bolus clearance,
residue and silent aspiration (Lazarus 2009); it is not
surprising, therefore, that weight loss and malnutrition
are commonly found in patients after RT for head and
neck cancers.
Dysphagia Evaluation and Treatment After Head and Neck Surgery 471
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Dysphagia may occur even many years after RT
(Smith et al. 2000); even if the precise cause is not
known, most authors agree that tissue fibrosis,
peripheral neuropathy and sensibility impairment are
responsible for late-onset dysphagia development.
Xerostomia is usually found even years after chemoradiotherapy and significantly impacts on patients’
perception of dysphagia and diet choices; however,
there is no correlation between saliva weight and
swallow function (Logemann et al. 2003).
4 Evaluation of Swallowing
and Swallowing Disorder
Complications after Surgery
and/or Chemo-radiotherapy
of Head and Neck Malignancies
Swallowing evaluation in patients after head and neck
cancer treatment relies on the same principles of
dysphagia of other origins: bedside clinical assessment and subsequent instrumental examination, either
videofluoroscopy or fiberoptic endoscopic evaluation
of swallowing (FEES). Before patient assessment, it is
critical to have detailed information on the surgical
procedure and the chemo-radiotherapy protocol; in
fact, it is crucial to know which structures have been
sacrificed or involved in an RT protocol. Clinical
and instrumental examinations aim to understand
the functions of the spared structures; in particular,
motion range, strength, and timing of the remaining
structures in swallowing and non-swallowing tasks
are critical for understanding bolus transit.
Clinical examination is important for the understanding of tongue and mouth structures and functions;
in particular, in patients with oral cancer, surgical and
non-surgical treatment protocols may have seriously
modified the anatomy and physiology of oral structures. FEES is recommended for a better definition of
mucosal status, velopharyngeal and laryngeal motility
as well as saliva and food residue. In particular, in the
early phases after treatment, when tracheotomy is still
in place, laryngeal assessment in retrograde vision
through stoma access (Fig. 15) gives important
information on laryngeal sensibility and aspiration
mechanisms; besides, FEES may be repeated several
times in order to establish when oral feeding may be
initiated, avoiding exposure to X-rays. FEES with
Fig. 15 Laryngeal assessment in retrograde vision through a
stoma access
sensory testing is recommended if available, since
laryngeal sensibility deficits are found in many
plays a critical role in establishing oral phase modification, severity of pharyngeal motion defects and
mechanisms of pharyngo-esophageal segment
dysfunctions.
The application of functional rating scales and
dysphagia-specific quality of life measures, such as
the M.D. Anderson Dysphagia Inventory or the
SWAL-QOL, provide important information on the
patient’s perception of swallowing (Chen et al. 2001;
McHorney and Robbins 2005). Use of these tools
helps recognize patients’ concerns, and helps define
therapy goals (Speyer et al. 2011).
Assessment of dysphagia complications (malnutrition and pulmonary complication) in head and neck
cancer patients does not differ from those of patients
with dysphagia of other origins. Since the risk of malnutrition is very high, all head and neck cancer patients
should be screened for nutritional status using a validated screening tool, appropriate to the patient population, such as the malnutrition universal screening
tool.
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Mendelsohn maneuver, and tongue-hold maneuver,
5 Treatment of Swallowing Disorders
after Surgery and/or Chemoradiotherapy for Head and Neck
Malignancies
All patients treated for head and neck cancers should
have access to a dysphagia team and to an instrumental investigation, if needed, in order to establish
adequate treatment. The primary treatment goal is to
maintain functional oral feeding and prevent aspiration and thoracic complications (SIGN 2006); QOL
improvement should be considered as a secondary,
but not less important goal (Gillespie et al. 2004;
Kulbersh et al. 2006).
Treatment mainly relies on swallowing rehabilitation, an emerging subspecialty of rehabilitation
(Gamble et al. 2011). Swallowing rehabilitation can
be divided into three main areas: preventative, compensatory and therapeutic exercises. While preventative rehabilitation after head and neck cancer surgery
has been little explored but seems to reduce recovery
time (Cavalot et al. 2009), there is a growing interest
in prophylactic swallowing exercises prior to commencing RT (Mittal et al. 2003; Rosenthal et al. 2006;
van der Molen et al. 2009b). These exercises focus on
maintaining tongue, jaw, pharyngeal constrictor
movement, hyo-laryngeal elevation, airway closure
and upper esophageal sphincter opening; typically
prescribed exercise are tongue range of motion, tongue strengthening, tongue base motion (effortful
swallow, tongue-hold maneuver, gargle), jaw range of
motion, Mendelsohn maneuver, Shaker exercise and
super-supraglottic swallow. Efficacy and compliance
data are emerging, but are not yet definitive. Compensatory strategies include postural changes (chintuck, head back, head tilt, head rotation, lying down),
swallowing maneuvers (super-supraglottic swallow,
Mendelsohn maneuver), and change in food consistency, temperature and taste; compensatory strategies
are well developed in the field of swallowing rehabilitation and their rationale and application do not
differ in head and neck cancer patients from patients
with other dysphagia related diseases. Therapeutic
exercises include a variety of exercises designed to
increase motion range and/or muscle strength of
specific muscle groups such as jaws, lips, tongue,
closure of the airways and laryngeal elevation; these
exercises include effortful swallow, Shaker exercise,
and they may be applied according to the residual
swallowing deficit after cancer treatment. Efficacy of
both compensatory strategies and therapeutic exercise
have been the object of investigation, showing preliminary positive effects (Nguyen et al. 2007; McCabe
et al. 2009).
Other treatment options for selected patients
include application of prosthetic devices, surgery and
enteral feeding. Prosthetic devices should be designed
to providemaximum functionalrehabilitation, asin the
case of palatal obturators to prevent velo-pharyngeal
insufficiency after oro-pharyngeal tumor resections.
Surgical options include pharyngeal or cervical
esophageal dilatation for hypopharyngeal or esophageal strictures, crycopharyngeal muscle myotomy for
upper esophageal sphincter spasm, and application of
fillers to reduce glottal insufficiency or tongue base
deficits (Bergamini et al. 2010). Tube feeding is
frequently adopted in the early phase after head and
neck cancer treatment and a percentage of these
patients remain on enteral feeding, even if there is not
enough evidence to decide on the optimal feeding
method (PEG or nasogastric tube); criteria to stop
enteral feeding are mainly related to the severity of
aspiration, even though there are differences in different centers (Logemann et al. 2008; Nugent et al. 2010).
Tracheostomy is frequently performed in head and
neck cancer patients for prevention of complications
due to post-operative edema or hemorrage, or where
supraglottic and glottic edema may occur during
chemoradiation. Management of the tracheostomy
tube and removal timing differ in different centers and
there is no consensus at the moment. However, the
effect of tracheotomy and the tracheotomy tube have
been the object of several investigations. It is reported
that the presence of an inflated cuff may impact on the
range of laryngeal motion and, as a result, airway
protection and crico-pharyngeal opening (Ding and
Logemann 2005). The possible causes of aspiration
after tracheostomy may be divided into mechanical
and neurophysiological factors. The mechanical factors are decreased laryngeal elevation and stasis of
secretions in the upper airway and cervical esophagus
due to local compressive forces exerted by the inflated
cuff. The neurophysiological factors were desensitization of the protective cough reflex and a loss of
co-ordination of laryngeal closure. Nonetheless, in
most cases, swallowing deficit in tracheostomized
Dysphagia Evaluation and Treatment After Head and Neck Surgery 473
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patients is not related to the tracheotomy itself, but to
the underlying disease that necessitated it (Leder et al.
2005; Leder and Ross 2010). Therefore, increased
aspiration risk or improvement in swallowing function after decannulation seems a clinical impressions
rather than a scientific evidence. Besides, it has to be
emphasized that an inflated cuff is not protection
against aspiration in tracheostomized patients. It is
important that prior to decannulation, the supraglottic
airway be evaluated to ensure successful removal of
the tube; patients should undergo instrumental evaluation of swallowing in both a cuff-inflated and
-deflated condition, thus returning those with adequate swallow function to oral intake.
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Behavioural Treatment of Oropharyngeal
https://t.me/med1917
Dysphagia: Bolus Modification
and Management, Sensory and Motor
Behavioural Techniques, Postural
Adjustments, and Swallow Manoeuvres
Rene´e Speyer
Contents
1 Introduction.............................................................. 477
2 Choice of Intervention Techniques........................ 479
3 Behavioural Treatment of Dysphagia ................... 479
3.1 Bolus Modification and Management....................... 480
3.2 Sensory and Motor Behavioural Techniques ........... 480
3.3 Postural Adjustments ................................................. 481
3.4 Swallow Manoeuvres ................................................ 482
3.5 Adjunctive Biofeedback ............................................ 484
4 Effects of Behavioural Treatment.......................... 484
4.1 Trends in Treatment Effects ..................................... 485
4.2 Methodology in Outcome Studies ............................ 488
5 Conclusion ................................................................ 489
References.......................................................................... 489
R. Speyer (&)
Mozartstraat 47, 6521 GB, Nijmegen,
The Netherlands
e-mail: r.speyer@online.nl
Abstract
This chapter gives an overview of the most
common behavioural techniques for treating oro-
pharyngeal dysphagia, namely bolus modification
and management, sensory and motor behavioural
techniques, postural adjustments, and swallow
manoeuvres. Each intervention is described along
with its rationale. Furthermore, in light of the
literature, the effects of dysphagia treatment are
discussed as are some methodological issues that
emerged from a review of outcome studies
1 Introduction
Evolution has endowed humans with an aerodigestive
tract that facilitates the combined functions of
breathing, vocalizing, and swallowing. The system
poses a risk of aspiration and choking, however, as a
result of the large supralaryngeal space created by
the rather low position of the larynx in adults. Any
dysfunction in this system may lead to swallowing
problems, a condition known as dysphagia.
The effect on a person’s health may be severe, as
dysphagia can lead to dehydration, malnutrition,
and aspiration pneumonia. It also affects people on a
social and psychological level, making mealtimes stressful and taking the pleasure out of going to
a restaurant. The possibility of suffocation, severe
coughing, and vomiting may also heighten one’s
anxiety and lower self-esteem. All these consequences
have a strong impact on quality of life as experienced
by dysphagic patients (McHorney et al. 2002). Yet
O. Ekberg (ed.), Dysphagia, Medical Radiology. Diagnostic Imaging, DOI: 10.1007/174_2011_350,
Ó Springer-Verlag Berlin Heidelberg 2012
477
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