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The Post-Operative Pharynx and Larynx 457
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Dysphagia Evaluation and Treatment
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After Head and Neck Surgery and/or
Chemo-radiotherapy for Head
and Neck Malignancies
Antonio Schindler, Francesco Mozzanica,
and Filippo Barbiera
Contents
1 Introduction.............................................................. 460
2 Surgical Options for Head and Neck
Malignancies............................................................. 460
2.1 Surgery for the Oral Cavity Malignancies ............... 460
2.2 Surgery for Oro-Pharyngeal Malignancies ............... 462
2.3 Surgery for Laryngeal Malignancies ........................ 463
2.4 Surgery for Neck Metastasis ..................................... 468
3 Chemo-radiotherapy for Head and Neck
Malignancies............................................................. 468
3.1 Effects of Chemo-radiotherapy on Mucosa, Cartilage
and Muscles ............................................................... 469
3.2 Effects of Chemo-radiotherapy on Swallowing ....... 470
4 Evaluation of Swallowing and Swallowing
Disorder Complications after Surgery and/
or Chemo-radiotherapy of Head and Neck
Malignancies............................................................. 471
5 Treatment of Swallowing Disorders after Surgery
and/or Chemo-radiotherapy for Head and Neck
Malignancies............................................................. 472
References.......................................................................... 473
A. Schindler (&) F. Mozzanica
Department of Biomedical and Clinical Sciences
‘‘L. Sacco’’, University of Milan, Via GB Grassi,
74 20157 Milan, Italy
e-mail: antonio.schindler@unimi.it
F. Barbiera
Unità Operativa di Radiologia ‘‘Domenico Noto’’,
Azienda Ospedali Civili Riuniti ‘‘Giovanni Paolo II’’,
92019 Sciacca, Italy
Abstract
Tumors ofthe head and neck represent 3.2 % ofnewly
diagnosed cancers; both surgery and chemo-radiotherapy are valid treatment options for head and neck
cancer. In many head and neck cancer patients,
dysphagia, malnutrition and aspiration pneumonia
are found and significantly impact on quality of life.
Dysphagia is related to the tumor itself, or consequences of its treatment. A large number of surgical
procedures, according to tumor site and extension,
patient age, and general conditions, have been developed and are reviewed in this chapter. Swallowing
disorders are related to both the surgical approach
(open or endoscopic) and the tissue removed; while
surgery for oral and oro-pharyngeal cancers mainly
impact onoral control, oralperistalsis and mastication,
partial laryngeal surgery interferes with airway protection mechanisms, and complete laryngeal removal
may be complicated with hypopharyngeal strictures.
Different chemo-radiotherapy protocols are available
nowadays and are reviewed here; dysphagia mayarise
in the first two years or even many years afterwards
and is mainly related to increased oro-pharyngeal
transit time, reduced tongue and pharyngeal strength,
restricted laryngealandhyoid elevation, poorvestibule
and true vocal fold closure and possibly abnormal
upper esophageal sphincter function. The primary
treatment goal of dysphagia in head and neck cancer
patients is maintaining functional oral feeding and
preventing aspiration and thoracic complications. All
patients treated for a head and neck cancers should
have access to a dysphagia specialist and to an
instrumental investigation in order to establish adequate treatment.
O. Ekberg (ed.), Dysphagia, Medical Radiology. Diagnostic Imaging, DOI: 10.1007/174_2012_606,
Ó Springer-Verlag Berlin Heidelberg 2012
459
460 A. Schindler et al.
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1 Introduction
Tumors of the head and neck are not rare, representing
3.2 % of newly diagnosed cancer (Curado and Hashibe
2009). Incidence and prevalence may vary due to
several factors: geographical area, area within the head
and neck , age, andtreatment. Bothsurgery and chemoradiotherapy are valid treatment options for head and
neck cancers andtheroles of these twoapproaches have
changed considerably over time; in fact, the evolution
of the treatment of head and neck cancers can be divided into three main periods. The first was focused on
curing patients using radical surgical procedures; the
second was developed to preserve speech, using sound
oncological principles. The final and current period is
of organ-sparing protocols utilizing a combination of
radiation, chemotherapy and surgery (Genden et al.
2007; Haigentz et al. 2009; Genden et al. 2010).
In many of the patients with head and neck cancer,
dysphagia as well as its complications (malnutrition
and aspiration pneumonia), are commonly found and
significantly impacton health and quality of life (QOL)
(Gallo et al. 2009; Manikantan et al. 2009; Schindler
et al. 2006). Different factors may contribute to the
presence of dysphagia: the tumor itself, the treatment
and, in a small percentage of patients, associated diseases, such as Parkinson’s or stroke. Swallowing
studies in patients with head and neck cancers revealed
signs of dysphagia prior to treatment in up to 59 % of
the population;pharyngeal tumorsappeared tobe more
often associated with dysphagia compared to oropharyngeal or laryngeal tumors and swallowing function
worsened significantly with increased tumor stage
(Pauloski et al. 2000; Stenson et al. 2000; Van der
Molen et al. 2009a). Appropriate management of
dysphagia in this non-uniform population requires a
team approach, with strict collaboration between
various professions including surgeons, oncologists,
radiotherapists, dentists, phoniatricians, speech and
language pathologists, and dieticians; a precise understanding ofthe disease, the treatment protocols, and the
patient’s will are necessary before swallowing assessment and rehabilitation planning (SIGN 2006). In this
chapter, only the main treatment options, for head and
neck cancers, both surgical and non-surgical, are
reviewed, with the aim of describing the impact on
swallowing and the dysphagia management of these
patients.
2 Surgical Options for Head
and Neck Malignancies
A large number of surgical procedures, according to
tumor site and extension aswell as thepatient’s ageand
general condition, have been developed over time to
treat head and neck malignancies. Head and neck
cancers are often treated with curative intent despite
frequent presentation with advanced-stage disease, an
intent thatmust be balanced with the potential for longterm morbidityfollowing aggressivelocal andregional
therapies. Head andneck cancers areclassified as either
‘‘resectable,’’ or technically ‘‘unresectable,’’ due to
regional invasion of critical structures; while ‘‘unresectable’’ tumors are often best treated with chemoradiotherapy, several curative-intent treatment options
currently exist forresectable tumors. Theadvantages of
surgery as primary therapy include complete pathological staging for determination of patient prognosis
as well as the potential for sparing some patients subsequent radiotherapy (RT), with or without chemotherapy with its attendant toxicity. However, possible
disadvantages of primary surgery include morbidity of
the procedure, postoperativefunctional impairment, or,
when the patient is not able to avoid postoperative
treatment, the toxicity of both surgical and subsequent
adjuvant therapy.
In most surgical procedures of the oral cavity,
pharynx and larynx a tracheotomy is performed in
order to prevent respiratory failure in case of oedema,
upper airway obstruction or peri-operative bleeding.
Appropriate management of the tracheotomy and of
the cannula are required in order to restore swallowing in the best possible way.
2.1 Surgery for the Oral Cavity
Malignancies
The oral cavity extends from the lip to the junction of
the hard and soft palate above and to the line of the
circumvallate papillae below; therefore the regions of
the oral cavity include buccal mucosa, upper and
lower alveolar ridges, the retromolar trigone, the
anterior two-thirds of the tongue, the floor of the
mouth, and the hard palate. Surgical procedures for
tumors of the oral cavity vary according to the site
and the dimension of the tumor; while for tumors
Dysphagia Evaluation and Treatment After Head and Neck Surgery 461
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to the tumor, and reconstruction. Depending on the
site and extension of the tumor, the possible tongue
resections are: marginal glossectomy (resection of
one-quarter of the tongue), hemiglossectomy (resection of half of the tongue along the midline), hemiglossomandibulectomy (resection of half of the
tongue and a portion of the mandible), and near total
glossectomy.
After marginal glossectomy or hemiglossectomy,
swallowing disorders are usually temporary and are
mainly related to clumsiness in tongue movement
and difficulties in triggering the swallowing re-flex.
Clumsiness in tongue movement may impact on both
control of material in the mouth and lingual peristalsis. When lingual resection exceeds 50 % of the
tongue, effects on swallowing are more severe. In
particular, lingual peristalsis and oral control may be
severely reduced (Fig. 2a, b); patients’ diets may be
restricted to liquids and thinned paste, and tilting of
the head backward to allow gravity to carry material
Fig. 1 Schematic drawing of split-thickness brachial flap after
resection of half of the tongue and mouth floor
into the pharynx is often required.
\4 cm surgery can be the only treatment option, for
larger tumors chemo-radiotherapy is usually preferred. The challenge of surgery for malignancies of
the oral cavity is to perform an adequate resection and
then to provide the best functional reconstruction
(de Bree et al. 2008). In fact, extensive surgical
resections are often required, leading to major physical defects that can-not be repaired by primary
mucosal closure or skin grafting. Surgical reconstruction aims to repair the physical deficit, while
restoring functional deficits. Reconstruction techniques are diverse and vary by anatomical region.
Split-thickness skin grafts are the mainstay for small,
superficial defects of the oral cavity (Fig. 1); the
pectoralis major myocutaneous flaps provide soft
tissue for large floor-of-mouth and tongue resections,
while myocutaneous or osteomyocutaneous free flaps
are the reconstructive methods of choice for oral
cavity defects. The radial fore-arm flap is the most
widely used free flap, while if bone is required for
mandibular reconstruction fibula, iliac crest or scapula, free flaps can be used.
2.1.1 Glossectomies
Tongue cancer surgery may vary depending on three
main variables: extension of tongue resection, access
2.1.2 Commando Procedures
The ‘‘commando procedure’’ (COMbined MANDibulectomy and Neck Dissection Operation) is a surgical procedure for malignant tumors of the floor of the
oral cavity, involving resection of portions of the
mandible in continuity with the oral lesion and radical
neck dissection. Segmental mandibulectomy is considered only when there is gross invasion of the
cancellous part of the bone by oral cancer, for primary
bone tumors of the mandible, metastatic tumors of the
mandible, invasion of inferior alveolar nerve or canal
by tumor, and for massive soft-tissue disease around
the mandible. In the other cases, since there are no
lymphatic channels passing through the mandible,
there is no need to perform an in-continuity composite
resection of the uninvolved mandible; in order to gain
access to the large primary oral cancer, a mandibulotomy can be performed without the need to sacrifice
the normal intervening mandible (Shah 2009).
Reconstructive surgery following resection for oral
cancer is considered when there is functional or
esthetic loss of structures in the oral cavity. Superficial surgical defects of the mucosa and underlying
soft tissues can be adequately reconstructed using a
skin graft, while larger defects of the tongue
exceeding one-half of the tongue or large surface
areas of the floor of the mouth, gum and buccal
462 A. Schindler et al.
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Fig. 2 Videofluoroscopic
images of a patient after
hemiglossectomy; poor oral
control with stasis in the floor
of the mouth and spillage in
the hypopharynx (a) as well
as aspiration (b) are visible
mucosa, require a free-tissue transfer. A radial forearm free flap provides excellent tissue for resurfacing
mucosal defects and underlying soft tissue deficiencies. The radial forearm flap is also an excellent
choice for reconstruction of any substantial resection
of the tongue. Fibula free flap reconstruction is currently the choice of reconstruction for defects following segmental mandibulectomy in any part of the
mandible. While other free flaps are available (from
iliac crest, scapula and the radial forearm), the fibula
provides the maximum length and bone stock to
achieve a satisfactory reconstruction of the lower jaw.
After resection of the anterior floor of the mouth,
swallowing is strictly related to surgical closure
technique, but it is usually preserved. If the tongue is
sutured into the surgical defect, however, impairment
of control of the bolus and of lingual peristalsis and
mastication will arise. After lateral mouth floor
resection, severe swallowing impairment may arise if
the base of the tongue is involved in the surgical
procedure; lingual propulsion and oral transit time
will be reduced and material will collect in the lateral
sulcus and/or in the crevices.
2.2 Surgery for Oro-Pharyngeal
Malignancies
The oropharynx consists of four sections: the soft
palate, tonsil, base of the tongue, and pharyngeal wall.
The survival outcomes of therapy for these tumors
remain essentially the same, regardless of the treatment combination employed. The most important
factor affecting long-term outcome following initial
treatment of oro-pharyngeal cancer is the stage of
disease at the time of presentation. In the past, surgery,
followed by RT, was standard. However, at present,
concurrent chemo-radiotherapy appears to be the
preferred choice of therapy. Surgical intervention
would be considered for tumors of minor salivary
gland origin or squamous cell carcinoma that remains
persistent after chemo-radiotherapy or recurs after
chemo-radiotherapy. Surgical access to neoplasms of
the oropharynx can be obtained via a mandibulotomy
(Fig. 3), lateral pharyngotomy or transoral robotic
surgery (TORS) (Weinstein et al. 2007). Early-stage
tumors offer excellent cure rates; however, once
regional lymph node metastases have taken place, a
significant drop in the cure rate is to be expected. Early
diagnosis and implementation of appropriate surgical
treatment based on tumor and patient factors, selective
management of regional lymph node metastases at
risk, and involvement of multidisciplinary teams for
implementation of adjuvant RT or chemo-radiotherapy, have all contributed to improvements in survival
of patients with oral cancers in the last few decades.
Contemporary surgical techniques of tumor resection
and reconstruction are essential to improve the quality
of life of patients following surgical resection due to
oro-pharyngeal cancer.
Surgery for oro-pharyngeal tumors impact on both
oral and pharyngeal stages of swallowing. Tongue
propulsion will be reduced, and there may be nasal
regurgitation as well as delayed or reduced triggering
of the swallowing reflex and pharyngeal peristalsis,
that lead to oral and pharyngeal residue. Occasionally, cricopharyngeal sphincter difficulties may also
arise.
Dysphagia Evaluation and Treatment After Head and Neck Surgery 463
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osteotomy, which is fixated at the end of the surgery.
It provides the widest and most reliable access to the
deep anatomy of the posterior oral cavity and oropharynx and lends exposure to virtually any site in the
upper aerodigestive tract, including the nasopharynx,
hypopharynx, parapharyngeal spaces, and clivus.
2.2.2 Lateral Pharyngotomy Access
Lateral pharyngotomy access is useful for smalltumors
of the base of the tongue and pharyngeal walls. The
pharynx is entered posterior to the thyroid ala on the
least diseased side. Once in the pharynx, the larynx is
retracted to the opposite side. This allows a good view
of the posterior pharyngeal wall, opposite lateral wall,
and base of tongue. If more superior exposure is needed, the pharyngotomy can be extended across the
vallecula or this approach can be combined with a lateral mandibulotomy.
2.2.3 Transoral Robotic Surgery
Robotic surgery is performed utilizing the da Vinci
surgical system. The surgeon sits at the console and
controlsmicromanipulators,whichinturnareconnected
to a robotic cart at the patient’s bedside. In TORS, three
arms are routinely utilized (Genden et al. 2009).
Fig. 3 Schematic drawing of transmaxillar-oropharyngecto-
my; the arrows indicate possible diffusione of the tumor
2.2.1 Mandibulotomy Access
Surgical access to the posterior oral cavity and oropharynx can be accomplished via a multitude of
approaches, including pull-through glossotomy and
pharyngotomy. In the pull-through technique, once
the hypoglossal and lingual nerves are identified, the
floor of the mouth mucosa and extrinsic tongue
muscles are divided and the tongue is dropped into the
neck (Fig. 4); when pharyngotomy is performed, neck
dissection is associated and resection of the upper
portion of the thyroid cartilage is necessary, before
incision into the pharyngeal wall. The most widely
used access is the mandibulomy, in particular the lipsplitting mandibulotomy approach. This involves a
lower lip-splitting incision, followed by a mandibular
2.3 Surgery for Laryngeal Malignancies
The era of surgical treatment began in 1873 when
Billroth first described the surgical procedure of total
laryngectomy (TL), the ‘‘gold standard’’ for advancedstage laryngeal carcinoma. Despite its efficacy as an
oncologic procedure, complete loss of thelarynxis a devastating experience that results in significant diminution of QOL for many individuals. The consequences of
TL include loss of nasal function, poor cough, swallowingdifficulties, lung function changesand,aboveall,
loss of the normal voice. Therefore, the challengeforthe
head and neck surgeon has not been significantly
improving the cure rate for laryngeal cancers because
the survival data for the radical laryngectomy have
remained quite constant when adjusted for tumor site
and stage, but reducing the morbidity associated with
the treatment (Dworkin et al. 2003;Levineetal.1997).
Not surprisingly, the evolution in the management of
laryngeal cancer has been toestablish surgicalas well as
non-surgical protocols with overall survival equivalent
to TL but better QOL (Genden et al. 2007).
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Fig. 4 Schematic drawing of
pull-through glossotomy
2.3.1 Partial Laryngectomies
There are several surgical options for treating laryngeal carcinoma, that allow resection of the tumor
with oncologically safe margin and preserve laryngeal
function. While fronto-lateral partial resections have
been used in the past, horizontal partial laryngectomies are currently more popular; horizontal partial
laryngectomies include supraglottic partial laryngectomy (SGL) and supracricoid laryngectomies (SCL).
Frontolateral vertical laryngectomy consists of a
vertical laryngectomy with removal of the anterior
commissure; a lateral thyrotomy is performed on both
sides, the vocal fold with the anterior commissure is
removed and the remaining vocal fold is sutured to the
thyroid cartilage. SGL consists of resecting the whole
supraglottic portion of the larynx, including both
ventricular folds and the epiglottis (Fig. 5). Depending
on the size and site of the tumor, SGL may be extended into the base of the tongue or may include one
arytenoid (Marandas et al. 1987). SCLs are conservative surgical techniques for the treatment of selected
laryngeal carcinomas; two reconstruction techniques,
cricohyoidoepiglottopexy (CHEP) and cricohyoidopexy (CHP) are used, depending on whether the
epiglottis is preserved or not (Adamopoulos et al.
2000; Brasnu 2003; Labayle and Bismuth 1971;
Laccourreye et al. 1987, 1990, 1995, 1996; Levine
et al. 1997; Piquet et al., 1974; Piquet and Chevalier
1991). In SCL, both ventricular and vocal folds as well
as the entire thyroid cartilage are resected, while at
least one arytenoid cartilage is spared; in SCL with
CHP (Fig. 6) the epiglottis and pre-epiglottic space are
also resected, while in SCL with CHEP they are spared
(Fig. 7). In the past few years, in addition to open
SCL, endoscopic CO
laser SCLs have been devel-
2
oped; this surgical approach reduces anterior neck
muscles and nerve involvement (Weinstein et al. 2007;
Jong-Lyel et al. 2008). Volitional sphincteric
approximation of the mobile arytenoids cartilage and
base of tongue, in the case of CHP, or epiglottis, in the
case if CHEP, allow neoglottal closure and airway
protection (Fig. 8), (de Vincentiis et al. 1996, 1998;
Luna-Ortiz et al. 2004; Naudo et al. 1997, 1998).
The advantage of partial laryngectomies over TL is
that a permanent tracheostomy is not required since
the main laryngeal functions (respiration, phonation
and swallowing) are preserved, when at least one
functioning cricoarytenoid joint is maintained, facilitating neoglottal competency (Bron et al. 2000).
Compensatory mechanisms with reorganization of the
stepwise sequence of neuromuscular events, lasting
several months, are necessary to restore swallowing
(Woisard et al. 1996; Yuceturk et al. 2005). Satisfactory functional results of both voice and swallowing
after partial laryngectomies have been reported by
various authors (Crevier-Buchman et al. 1995, 1998;
Zacharek et al. 2001); however, significant alterations
have become inevitable and long-term outcome
Dysphagia Evaluation and Treatment After Head and Neck Surgery 465
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Fig. 5 Schematic drawing of
horizontal sovraglottic
laryngectomy
showed mild to moderate dysphagia in the majority of
patients (Schindler et al. 2006, 2009).
While vertical partial laryngectomy usually does not
impact on swallowing, horizontal partial laryngectomies are associated with dysphagia mainly due to
airway protection impairment, and they require
appropriate management by a swallowing therapist; in
all the reported case series, a small but significant
percentage of patients developed aspiration pneumonia and a few did not achieve the ability to eat by
mouth. Severity of dysphagia and recovery time are
mainly related to amplitude of resection: after SGL
swallowing recovers sooner than after SCL with CHP,
but SGL extended to the base of the tongue is associated with more severe dysphagia compared to SGL.
Insufficient laryngeal vestibule and/or glottis closure
during the pharyngeal phase of swallowing is seen in
all these patients, and appropriate laryngeal closure
needs to be acquired after surgery (Rademaker et al.
1993). While upper airway protection deficit is the
main cause of dysphagia, other factors should be
considered: superior laryngeal nerve function is often
impaired, leading to a reduced laryngeal sensation;
laryngeal elevation can also be damaged and upper
esophageal sphincter opening reduced. Finally, a
delayed swallowing reflex is found in a significant
percentage of patients (Fig. 9).
In the long term aspiration is found in about 40 % of
patients who underwent SCL and who are by mouth
feeded (Fig. 10); nonetheless, pulmonaryCTscans fail to
find significant differences compared to COPD patients,
suggesting that in this population, a mild chronic aspiration is well tolerated (Simonelli et al. 2010).
2.3.2 TL and Laryngopharyngectomy
TL is the widely accepted standard for surgical treatment of advanced laryngeal and hypopharyngeal
tumors. TL includes removal of all laryngeal and
associated structures, from the hyoid bone and the
epiglottis superiorly to the tracheal rings inferiorly,
with varying amounts of the hypopharynx and thyroid
gland. It can be extended to the base of the tongue,
pharynx andtrachea as well as prelaryngeal soft tissues
including the skin (Fig. 11). Whenthe tumor originates
in the hypopharynx or there is a hypopharyngeal
extension of laryngeal carcinoma, a partial or total
laryngopharyngectomy may beneeded.If the extension
is limited, partial pharyngectomy is performed, while
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Fig. 6 Schematic drawing of surpacricoid laryngectomy with crico-hyodo-pexy (CHP); only one arytenoid is spared
Fig. 7 Schematic drawing of
surpacricoid laryngectomy
with crico-hyodoepiglottopexy (CHEP)
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