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ysphagia in Head and Neckancer Patients Treated With Radiation:ssessment, Sequelae, and Rehabilitation

arbara A. Murphy, MD, and Jill Gilbert, MD

Dysphagia is commonly seen in patients undergoing radiation-based therapy for locallyadvanced squamous carcinoma of the head and neck. Within 4 to 5 weeks of startingtherapy, patients develop mucositis, radiation dermatitis, and edema of the soft tissues.Resulting pain, copious mucous production, xerostomia, and tissue swelling contribute toacute dysphagia. As the acute effects resolve, late effects including fibrosis, lymphedema,and damage to neural structures become manifest. Both acute and late effects result inadverse sequelae including aspiration, feeding tube dependence, and nutritional deficien-cies. Early referral for evaluation by speech-language pathologists is critical to (1) ensureadequate assessment of swallow function, (2) determine whether further testing is neededto diagnose or treat the swallowing disorder, (3) generate a treatment plan that includespatient education and swallow therapy, (4) work with dieticians to ensure adequate andsafe nutrition, and (5) identify patients with clinically significant aspiration.Semin Radiat Oncol 19:35-42 © 2009 Elsevier Inc. All rights reserved.

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ith the increasing use of aggressive combined modal-ity therapy and altered radiation techniques for the

reatment of locally advanced head and neck cancer (HNC),he acute and late effects of treatment have become an area ofntensive interest and investigation. One problem that hasarnered attention is dysphagia associated with radiation-ased function-sparing techniques. Radiation oncologistsnd medical oncologists treating HNC must be familiar withhe basics of normal swallowing, the underlying mechanismy which radiation induces acute and late effect dysphagia,ow swallowing is affected by treatment, the consequence ofysphagia, and the role of swallowing therapy in the preven-ion and treatment of dysphagia.

ormal Swallowing Functionwallowing is a complex process that requires the preciseoordination of over 25 pairs of muscles in the oral cavity,harynx, larynx, and esophagus.1 Neural control of swallow-

ng, which has both voluntary and involuntary components,s mediated by interactions between cortical centers in bothemispheres, the “swallowing center” within the brainstem,

anderbilt Ingram Cancer Center, Vanderbilt University, Nashville, TN.ddress reprint requests to Barbara A. Murphy, Vanderbilt-Ingram Cancer

Center, 2220 Pierce Avenue, 777 Preston Research Building, Nashville,

aTN 37232-6307. E-mail: barbara.murphy@vanderbilt.edu

053-4296/09/$-see front matter © 2009 Elsevier Inc. All rights reserved.oi:10.1016/j.semradonc.2008.09.007

ranial nerves (V, VII, IX sensory, IX motor, X and XII), andharyngeal receptors (touch, pressure, chemical stimulus,nd water).2 The normal swallow (Table 1) is usually dividednto 4 phases: oral preparation, oral, pharyngeal, and esoph-geal.2 During the oral preparatory phase of swallowing, foods ground and mixed with saliva to form a food bolus. Theolus is then transported to the pharynx during the oralhase. During the pharyngeal phase, the swallowing reflex isriggered, resulting in (1) closure of the larynx to preventspiration; (2) contraction of the pharyngeal constrictorsrom superior to inferior; (3) laryngeal elevation, epiglotticnversion; and (4) relaxation of the cricopharyngeus to allowhe food bolus to pass into the esophagus.3,4 During the finalhase, the peristalsis of the esophageal muscles results inovement of the bolus into the stomach. Disruption in any of

hese functions can result in dysphagia.

wallowing Assessmentwallowing assessment and therapy should be undertaken byertified speech-language pathologists (SLPs). SLPs shoulde considered an integral part of the treatment team for allatients with HNC.5 SLP should be consulted early in treat-ent planning whenever possible and should provide rou-

ine follow-up so that they can intervene when necessary.he SLP will perform a clinical evaluation of swallowing.6 As

part of the clinical evaluation of swallowing, the SLP will

35

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1) assess swallow function to determine whether there are anywallowing abnormalities present, (2) determine whetherurther testing is needed to diagnose or treat the swallowingisorder, (3) generate a treatment plan that includes patientducation and swallow therapy, (4) work with dieticians tonsure adequate and safe nutrition, and (5) identify patientsith significant aspiration risk.Although referral for swallow assessment should be a part

f the routine care and treatment of HNC patients, the treat-ng physician should be aware of signs and symptoms thatuggest clinically significant aspiration. “Trigger symptoms”hat herald dysphagia are listed in Table 2.5,7 Of particularoncern are symptoms that indicate potential aspiration, in-luding coughing or clearing the throat before, during, orfter eating. Should patients develop any of these symptoms,n immediate referral for assessment by an SLP should beonsidered.

There are a number of instrumental methods for assessingwallowing function. The most commonly used method ishe modified barium swallow study (MBSS).8 The MBSS is aideofluoroscopic examination that allows evaluation of theral and pharyngeal function. The purpose of the study waso identify disorders that impair swallowing, identify aspira-ion and the risk for pneumonia, and judge the patients’

able 1 Phases of normal swallowing2-4,59

ral preparatory phase:● Teeth, lips, cheeks, tongue, mandible, and palate

grind and manipulate food● Food mixed with saliva● Formation of a food bolus consistency appropriate for

safe swallowral phase: (duration approximately 1 second)● Lips and cheeks contract● Tongue presses the food bolus against the hard palate

and soft palate elevates● Food bolus is moved backwards by the tongue● A central groove is formed in the tongue for passage

of bolus● Bolus is moved to the tonsillar pillars, thus initiating

the oral phase of swallowing● The soft palate moves superior and posterior to close

off nasopharynxharyngeal phase: (duration approximately 1 second)● Piston-like action of tongue to propel food posteriorly● Closure of the larynx to the level of the true and false

vocal cords● Retroversion of the epiglottis over the laryngeal

vestibule● Closure of the laryngeal vestibule● Elevation of the larynx under the tongue base● Contraction of the pharyngeal constrictors● Relaxation of the cricopharyngeal muscles● Opening of the cricopharyngeal sphincter by upward

and forward movement of the larynxsophageal phase: (duration approximately 3 to 4 seconds)● Peristaltic contractions of musculature results in

movement of the bolus into the stomach

bility to maintain nutrition and hydration. Standardized ●

rotocols have been established that test swallowing capacitysing contrast containing food boluses of varying sizes andonsistencies, thus allowing the SLP to make dietary recom-endations for patients with swallowing impairment. If ab-ormalities are identified, various compensatory measurespostural techniques, increased sensory input, and voluntarywallowing maneuvers) can be assessed for efficacy.

A second commonly used tool to assess swallowing is theexible endoscopic evaluation of swallowing safety (FEES).EES allows direct visualization of the nasopharynx, base ofongue, hypopharynx, larynx, and vocal folds.9 Importantspects of function can be assessed including management ofecretions, sensory deficits, and muscular function of theharyngeal constrictors. Of particular importance, FEES al-

ow direct visualization of the larynx with identification ofremature spillage, pooling, laryngeal penetration, aspira-ion, and laryngopharyngeal reflux.10 The study procedure isafe and can be done at the patient bedside if needed.9 FEESoes not assess the oral cavity and opening of the uppersophageal sphincter. Thus, many clinicians believe that theBSS and the FEES provide complementary information.

echanism ofadiation-Induced Dysphagia

t has long been recognized that HNC and its treatment resultn alterations in swallowing functioning. The cause of dys-hagia for patients undergoing resection is evident. Tissue

oss because of surgical excision, transection of muscles anderves, and resulting scar and loss of sensation result inarked alteration in the functioning of tissues vital for nor-al swallowing. Data from the surgical literature indicate that

he extent of dysphagia correlates with the site of primary,11 theize of the tumor,12 the extent of surgical resection,13 and theype of reconstruction.14

Radiation therapy may also result in significant acute andate effect dysphagia, but the etiology of the underlying tissueamage differs. Acutely, radiation therapy results in damageo the mucosa and soft tissue within the radiation treatmentolume.15 This results in an inflammatory reaction and theroduction of reactive oxygen species.16 Clinically, the pa-

able 2 Triggers for dysphagia evaluation5,7

Inability to control food, liquids, or saliva in the oralcavityPocketing of food in cheekExcessive chewingDroolingCoughing, choking, or throat clearing before, during, orafter swallowingAbnormal vocal quality after swallowing; “wet” or“gurgly” voiceBuildup or congestion after a mealComplaint of difficulty swallowingComplaint of food “sticking” in throatNasal regurgitation

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Dysphagia in head and neck cancer 37

ients develop mucositis, radiation dermatitis, and edema ofhe soft tissues. Pain, thickened and more viscous mucousroduction, xerostomia, and tissue swelling contribute tocute dysphagia.17 By 3 months after treatment, clinical acuteffects have largely resolved, and swallowing function beginso return for most patients. Nonetheless, a “continuing cas-ade of cytokines” results in ongoing effects on tissue second-ry to radiation. Tissues become fibrotic and rigid with re-ultant loss of function. It is hypothesized that ongoingypoxia and chronic oxidative stress may perpetuate tissueamage long after treatment has been completed,18,19 thusxplaining why some patients develop dysphagia years afterherapy has been completed. Late-effect lymphedema andadiation-induced damage to neural structures may also con-ribute to dysphagia.

wallowing Abnormalitiesecondary to Radiation Therapy

NC patients often present with swallowing abnormali-ies20,21 Thus, prospective studies are needed to distinguishhe effect of tumor versus treatment on the incidence and

able 3 Common swallowing abnormalities because of radia-ion therapy

bnormalities in the oral preparatory and oral pharyngealphase:

● Limitations in lip closure● Results in drooling● Loss of cheek muscles● Results in pocketing of food in cheek● Trismus● Impacts oral opening and bite range● Tongue weakness or decreased tongue elevation and

lateralization● Limits positioning of the food bolus● Spillage of bolus into valleculae and pyriform sinuses● Increase oral transit time and number of swallows● Decreased sensory input● Delayed swallow initiation

bnormalities in the pharyngeal phase:● Epiglottis edema, decreased motion. and inversion● May result in risk of aspiration● Decreased tongue base retraction● May result in risk of aspiration● Decreased contraction of pharyngeal constrictors

Pauloski BA, Logemann JL: Impact of tongue baseand posterior pharyngeal wall biomechanics onpharyngeal clearance in irradiated post-surgical oraland oropharyngeal cancer patients. Head Neck 2000:22(2):120-131.

● Affects transport of bolus through the pharynx● Affects clearance from the pharynx● Decreased laryngeal elevation● Increased risk of laryngeal penetration/aspiration● Decreased anterior movement of larynx:● Decreases cricopharyngeal opening which results in

increase pharyngeal residue

everity of late-effect dysphagia. Most studies evaluating late-

ffect dysphagia will begin assessments at 3 months afterreatment when the acute effects of treatment have resolved.s noted earlier, many of the abnormalities identified on MBSnd FEES are secondary to decreased compliance and con-ractility of soft tissues and muscles because of fibrosis andymphedema. Muscle weakness because of atrophy and loss ofensation may also contribute to swallowing abnormalities. Ta-le 3 lists commonly identified abnormalities in swallowingunction in patients treated with radiation therapy–based treat-ent regimens. The type of swallowing abnormality corre-

ates with the primary site with lower oropharyngeal swallowfficiency (OPSE) scores for patients with oropharyngeal, hy-opharyngeal, and laryngeal tumors.22 It is beyond the scopef this review to discuss these abnormalities in detail, but theeader is referred to the article by Mittal et al23 for an in-depthiscuss of this topic (Table 4).An important but less commonly discussed manifestation

f late-effect dysphagia is stricture formation. Lee et al24 re-orted the results of a retrospective study of 199 patientsreated with chemoradiation. Of 82 patients who underwentwallowing evaluation, 41 patients were found to have a stric-

able 4 Examples of exercises and maneuvers for dysphagiaherapy

endelsohnmaneuver

Voluntary prolongation of laryngealexcursion and cricopharyngeal openingduring swallowing

Participants initiate the swallow and“hold” the larynx in the elevatedposition for 5 seconds, using themuscles of the neck

hakerexercises

Targets upper esophageal sphincterdysphagia

Patients lie flat on their back and lift thehead 4 inches and look at their toeswithout lifting the shoulders

Extended or repetitive formatffortfulswallow

Targets reduced pharyngeal peristalsiswith residue after swallow

Participant swallows hard, squeezing thetongue and walls of the throat together

upraglotticswallow

Targets decreased airway protection,aspiration by increasing airwayprotection with closure of true vocalfolds, dispels residue above the glottisafter the swallow

ompensatorypositions

Chin tuck/chin to chest: help withreduced bolus control, prematurespillage into larynx, decreased tonguebase movement

Head rotation to affected side:compensatory measure for unilateralpharyngeal paresis or unilateral vocalfold dysfunction or cricopharyngealdysmotility

ral stageexercises

Includes lip closure, lingual and jaw ROM

ase of tongue Includes tongue retraction, yawn/gargle,

exercises Masako

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ure (21% of total). Predictors for stricture formation includedwice-per-day radiation, female sex, and hypopharyngeal pri-ary. All 41 patients underwent dilation for treatment (16 pa-

ients: 1 dilation procedure, 17 patients: 2 procedures, and 8atients: 3 or more). The efficacy of the dilations was not re-orted. An interesting side note to this study is the fact that morehan half of strictures occurred below the area that receivedigh-dose radiation. The authors hypothesize that decreasedwallowing may result in increased fibrosis.

isk Factorsor Postradiationwallowing Abnormalities

everal risk factors have been identified for the developmentf swallowing abnormalities secondary to radiation-basedreatment. The structures within the radiation port and radi-tion techniques appear to influence late effects. Eisbruch etl25 have identified “dysphagia/aspiration-related structures”DARSs). DARSs are anatomic structures that when damagedy radiation therapy result in dysphagia and aspiration. Theyave shown that the use of IMRT can minimize radiation tohese structures. Furthermore, they showed that minimizingadiation to select DARS may result in improved swallowingutcomes.26 Similarly, Fua et al27 showed that patientsreated with IMRT fields junctioned with an anterior neckeld with central shielding for nasopharyngeal carcinomaad significantly less grade 3 dysphagia and reduced lengthf feeding tube placement.It may be hypothesized that increased acute inflammationay increase late-effect fibrosis and lymphedema resulting in

ncreased dysphagia. Acute tissue damage heals in 2 distincthases: a regenerative phase and a fibrosis phase. During theegenerative phase, tissues repair and are replaced by similarell types. During the fibrotic phase, the normal cells areeplaced by connective tissue.28 It may be hypothesized thathen the acute reaction is protracted or over exuberant, the

epair process transitions from being beneficial to becomingarmful. The use of chemotherapy concurrently with radia-ion therapy clearly increases the rate of grade 3 and 4 mu-ositis.29 Does the increase in acute mucositis result in increasedbrosis and late-effect dysphagia? Clinical experience wouldupport this hypothesis; however, well-conducted studies torove this are lacking.18 One study comparing concurrent regi-ens found no difference in swallowing function.22

An additional factor that may contribute to acute and latewallowing abnormalities is the use of feeding tubes. There isonsiderable variability in practice patterns regarding the usef feeding tubes. Some clinicians place a prophylactic feedingube in all patients undergoing treatment for locally advancedisease. Data would support the fact that patients whondergo tube placement prophylactically experience lesseight loss.30,31 Thus, some clinicians argue for the use ofrophylactic feeding tube placement in all patients with lo-ally advanced disease who are undergoing aggressive com-ined modality treatment regimens. Others argue that the

lacement of a feeding tube leads to decreased use of muscles p

f mastication and swallowing with resultant atrophy.18,32

urthermore, patients undergoing aggressive chemoradia-ion regimens experience profound muscle loss, which notnly contributes to generalized debility but may also contrib-te to the deterioration in swallow function.33 Data clarifyinghis relationship are needed.

Several other risk factors should be considered. Adequateubrication is critical for normal swallowing function. Xero-tomia secondary to chemotherapy, radiation, or medica-ions may significantly affect food bolus formation and swal-owing function and contribute to dysphagia.34 Patientsndergoing neck dissection after organ-preservation strate-ies have been shown to have an increase in percutaneousndoscopic gastrostomy (PEG) tube dependence.35 Patientsith a tracheostomy tube may experience increased difficultyith swallowing. Finally, genetic predisposition may explainifferences in the observed late effects on a patient-by-patientasis.

omplications of Dysphagiahere are several important sequelae to oropharyngeal dys-

unction. One of the most recognized is aspiration. Breathingnd swallowing are physiologically linked events. They areimed in such a way as to ensure that the airway is protecteduring pharyngeal swallowing. Disordered swallowing mayesult in aspiration, pneumonia, and chronic bronchial in-ammation. Aspiration is defined as the passage of materialselow the true vocal cord. Aspiration may occur at differenthases of swallowing: (1) before the pharyngeal phase be-ause of the loss of control of the tongue or delayed reflexivewallowing, (2) during the pharyngeal phase because of in-dequate airway closure, and (3) after the pharyngeal phaseecause of retained materials in the pharynx.36 Aspirationsually manifests itself by cough or clearing of the throatefore, during, or after swallowing.Unfortunately, silent aspiration is frequent in irradiated

NC patients.37 Furthermore, the cough reflex is ineffectiver absent in almost half of patients.38 Although some degreef aspiration may be tolerated by patients, particularly if theyave an intact cough reflex, it is critical to identify patientsith clinically significant aspiration. The consequences of

spiration are often underappreciated. Nguyen et al39 re-orted on 55 patients treated with chemoradiation. Eightatients developed aspiration pneumonia; 5 died because ofneumonia. Contributing factors to the high morbidity/mor-ality was weight loss with accompanying immune suppres-ion because of neutropenia.

A second common complication of late-effect dysphagia isermanent or long-term feeding tube dependence. Althoughatients may receive adequate nutrition via a feeding tube,here are many negative aspects of tube feeding that impactn patients and their families; tube feedings are expensivend may not be covered by insurance, feedings are time in-ensive and may require disruptions in the patients’ activity,nd minor complications are frequent. Of note, the presencef a feeding tube has been shown to be the most powerful

redictor of quality of life in HNC patients 1 year after treat-

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Dysphagia in head and neck cancer 39

ent.40 Predictive factors for permanent feeding tube place-ents have been identified. Cheng et al41 conducted an anal-

sis of 724 HNC patients who had completed therapy ainimum of 1 month before study enrollment. Fourteen per-

ent of patients had a feeding tube in place. Predictors ofeeding tube placement included oro/hypopharyngeal prima-ies, stage III/IV disease, flap reconstruction, current trache-tomy, chemotherapy, or increased age. Of note, as the pop-lation ages, patients experience increasing baseline swallowingysfunction.42 Thus, particular care should be taken to identifywallowing issues in the elderly patients.

Finally, patients with swallowing abnormalities may con-ciously or unconsciously alter the type and consistency ofood that they eat. Although some dietary changes are adap-ive, others are maladaptive and result in nutritional deficien-ies.43,44 Long-term dietary inadequacies can lead to malnu-rition with its associated adverse effects.

revention andreatment of Dysphagiaiven the high complication rate and adverse impact onuality of life, it is critical to minimize dysphagia and itsequelae. Unfortunately, there have been few prospective,andomized trials evaluating preventive or therapeutic dys-hagia interventions in the HNC population. That being said,

t is important to understand current standards of care as wells areas of ongoing investigation.

reatment Modificationshe balance between efficacy and toxicity in treatment ofNC is tenuous. With aggressive chemoradiation regimens,

he maximum tolerated dose has been reached. Two majorpproaches can be taken to modify treatment regimens toptimize the therapeutic ratio: (1) the addition of supportiveare agents that ameliorate toxicity or (2) alteration of thereatment regimen itself to minimize adverse events. Amifos-ine, a free-radical scavenger, is an example of a supportiveare agent that can be added to treatment regimens to mini-ize adverse events. Currently, amifostine is Food and Drugdministration approved as a salivary gland cryoprotectanturing radiation therapy. Randomized controlled studiesave shown its efficacy in the prevention of radiation-associ-ted xerostomia.45 Theoretically, decreased xerostomia maymprove management of the food bolus34 with a resultantecrease in swallowing difficulties. Furthermore, decreasedcute mucosal toxicity may potentially lead to decreased fi-rosis and late swallowing effects. A meta-analysis evaluatinghe efficacy and toxicity of amifostine showed a significantlyecreased incidence of dysphagia in patients treated withmifostine during HNC radiation-based therapy (P � .04;dds ratio � 0.26; confidence interval, 0.07-0.92).46 Theumber of patients included in the analysis was small, but theata are provocative. The benefit of amifostine when given inonjunction with chemoradiation is poorly defined.

Intensity-modulated radiation therapy (IMRT) can be used h

o spare structures that are critical for swallowing function.ata clearly indicate that IMRT can spare the salivary glandsnd decrease treatment-associated xerostomia, which maymprove oral phase function. Furthermore, a dose-responseelationship exists between dysphagia and radiation to theuperior and middle pharyngeal constrictor muscle.25 Thus,MRT may minimize radiation to “bystander tissues” that arenvolved in the biomechanics of swallowing. To that end,isbruch et al26 evaluated whether IMRT or brachytherapyan reduce dysphagia in HNC patients. The dose-responseelationship for the swallowing structures and dysphagiaupported the use of “controlled” radiation techniques suchs IMRT and brachytherapy (BT) to lessen the RT dose to thepper and middle pharyngeal constrictors.26 Similarly, Mittalt al23 showed that the use of tissue/dose compensation re-ulted in lower pharyngeal residue and better oropharyngealwallowing efficiency.

ehabilitation: Theole of Swallowing Therapy

or the patient who is experiencing swallowing abnormali-ies, the SLP will make recommendations regarding (1) safewallowing strategies with an emphasis on avoiding aspira-ion, (2) therapeutic postures and exercises that may improvewallowing function over time, and (3) modifications in dieto ensure safe and adequate oral intake. It is critical that theatient, family, and health care team are informed aboutecommendations. For hospitalized patients, staff may needo implement specific procedures to ensure safe swallowingeg, adjusting the patient’s posture, administering liquid orrushed medications, and adjustment in feeding rates or con-tancy). For patients in the home environment, the patientnd family are responsible for carrying through recommen-ations. Thus, education is a critical component of an ade-uate SLP consultation.The major techniques used by SLP for swallowing therapy

re (1) postural techniques, (2) sensory techniques, (3) mo-or exercise, (4) swallowing maneuvers, and (5) changes iniet (Table 4).23,42 Postural techniques are changes in bodyosition that maximize swallow function and minimize aspi-ation. Logemann47 described in detail the rationale for these of various postural techniques based on the disorderbserved. Increased sensory response may be attemptedhrough several techniques including stimulation via pres-ure, alterations in temperature, or alterations in taste. How-ver, the most commonly used method is to alter the bolusonsistency, placement, or size. The goal of motor exercise iso increase strength, mobility, and endurance of swallowingtructures.48 These techniques are used when weakness oross of range of motion has been identified on swallowingvaluation.49 Swallow maneuvers are used to place specificspects of swallowing function under volitional control. Theynclude the supraglottic swallow, the supersupraglottic swal-ow, the effortful swallow, and the Mendelsohn maneuver.50

nder fluoroscopic or endoscopic guidance, the SLP can

elp identify the techniques that are most effective for max-

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40 B.A. Murphy and J. Gilbert

mizing swallow efficacy for the individual patient. Resultsay be enhanced when patients receive visual feedback fromBSS, FEES, electomyographic biofeedback systems, andonometers that measure intraoral pressure.51

More recently, neuromuscular electrical stimulation (NES)as been used as an adjunct to swallowing therapy. DuringES, the muscles are stimulated in an attempt to increaseotor strength. Definitive studies showing efficacy in theNC patient population are lacking. Carnby-Mann andrary52 conducted a meta-analysis to assess the effect of NESn swallowing. Of 81 trials reviewed, only 7 were included inhe analysis. A small but significant effect size favoring NESas noted.

ritical Issues inwallowing Rehabilitation

fficacylthough the use of swallowing rehabilitation is generallyelieved to be efficacious, there are few rigorous prospectiveandomized studies in HNC patients treated with concurrenthemoradiotherapy (CCR). It may be argued that such trialsre needed because the majority of patients may recoverwallowing function over time without the addition of swal-owing rehabilitation. Large prospective randomized trialsomparing swallowing rehabilitation versus observationould be difficult to conduct, however. First, there are ethi-

al concerns about withholding therapy for patients withignificant dysfunction. In addition, HNC patients constituteheterogeneous population, and it would be very difficult to

dentify patients with identical swallowing impediments.Recognizing these caveats, available data would support

he recommendation that swallowing evaluation and rehabil-tation be offered to all patients with locally advanced HNCndergoing CCR. Logemann et al53 evaluated the relation-hip of speech and swallow dysfunction with the use of rangef motion exercises between 1 and 3 months postoperativelyor oral cavity or oropharyngeal cancer. Although this wasot a population treated primarily with CCR, the investiga-ors showed a significant correlation between range of mo-ion exercises and oropharyngeal swallow efficiency on liq-ids. Significant differences were also noted for globalwallowing measures, favoring the ROM group.53 Posturalechniques clearly result in decrease aspiration by 50% to5%.38,54 Swallowing exercises may improve swallowing ef-cacy.55

iminghe optimal timing of swallowing therapy has not been es-

ablished. Clearly, even brief periods of oropharyngeal restre associated with dysphagia.56 Furthermore, data wouldupport the concept that there is a “window of opportunity”uring which dysphagia rehabilitation may be optimized.his may relate to the development of fibrosis, the effects ofhich are difficult to ameliorate. Logemann et al53 showed

hat at baseline, the majority of patients show some evidencef swallow dysfunction. Moreover, the greatest increase in

wallow disorders was noted at 3 months after CCR, with no

ignificant improvement in many of these disorders by 12onths after CCR53 (ie, if disorders were noted at 3 months,

ignificant recovery was not the rule). Others have shownimilar findings. Denk et al12 reported on prognostic factorsor swallowing rehabilitation after head and neck surgery.hey found that patients who were referred for early therapyad improved outcomes. Thus, speech and swallow inter-ention should be considered early after CCR.

Based on data that indicated that early swallowing rehabil-tation is superior to late swallowing therapy, the questionrose as to whether pretreatment swallowing exercise couldurther improve late effects. Kulbersh et al57 conducted aetrospective, cross-sectional assessment of swallow func-ion, comparing 25 patients who received pretreatment swal-owing exercises with 12 patients who received standardare. Patients who received swallowing therapy had an im-rovement in swallowing as assessed by the M. D. Andersonysphagia Inventory (70.4 v 47.1, P � .0083). Similarly,arroll et al58 evaluated the efficacy of pretreatment rehabil-

tation in 18 patients with advanced HNC who received che-oradiotherapy (CCR). Nine patients received pretreatment

wallowing exercises, starting 2 weeks before CCR includinghe tongue hold, tongue resistance, effortful swallow, the

endelsohn maneuver, and Shaker exercises. The authorsound that patients in the pretreatment arm had significantlymproved posterior tongue base position during swallow andmproved epiglottis inversion over the control group. Noignificant differences were noted in PEG use 12 months afterCR.58 The utility of pretreatment swallow intervention re-ains an area of active investigation.

onclusionsNC patients undergoing chemoradiation are at high risk for

cute and late-effect dysphagia. Therefore, the SLP should beonsidered an essential part of the treatment team. One of theritical sequela of dysphagia is aspiration. Postural maneu-ers can decrease the rate of aspiration in a high percentage ofatients. In addition, available data would indicate that swal-

owing rehabilitation can improve outcomes. Although theata are limited, early intervention appears to be superior toelayed intervention. Furthermore, methodologically soundtudies to evaluate interventions to improve swallowing areeeded.

cknowledgmentse would like to than Anne Tomlinson for her assistance inanuscript preparation and Carmin Bartow and LauracBride for reviewing the completed article.

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Dysphagia in head and neck cancer 41

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