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Clin Exp Otorhinolaryngol
v.6(3); 2013 Sep
PMC3781223

Clin Exp Otorhinolaryngol. 2013 Sep; 6(3): 117126.

Published online 2013 Sep 4. doi: 10.3342/ceo.2013.6.3.117
PMCID: PMC3781223

Dysphagia in Head and Neck Cancer

Patients: Pretreatment Evaluation,
Predictive Factors, and Assessment during
Radio-Chemotherapy, Recommendations
Nerina Denaro, 1 Marco C. Merlano,1 and Elvio G. Russi2
Author information Article notes Copyright and License information
This article has been cited by other articles in PMC.

Abstract
Go to:

INTRODUCTION
Progress in head and neck cancer (HNC) treatments has improved tumour response
and loco-regional control rates. However, despite improved diagnostic and
therapeutic approaches, mortality remains high [1,2].
Intensification of treatment with chemoradiotherapy (CRT) or altered fractionation
radiotherapy (RT) is associated with improved outcome, but causes severe early
and late mucosal and pharyngeal toxicities. Oropharyngeal dysphagia is an
underestimated symptom in HNC patients [3,4].
Frequent causes of dysphagia in this population include neurological and
neuromuscular impairment, and structural and iatrogenic causes. Dysphagia should
not be neglected, as it can profoundly diminish the quality of life (QoL) [5]. The
resulting impaired swallowing can cause malnutrition and dehydration, and might
lead to aspiration pneumonia. Swallowing disorders are often predictable,
depending on both tumor associated structures and treatment modalities. A correct
pretreatment selection for patients at highest risk for dysphagia could optimize
functional and therapeutic results [6,7]. A multidimensional approach should
consider treatment targets and acute and late toxicities. For most patients the
highest priority is cure, therefore considerations about late treatment-related
toxicities should not prevent the use of proven aggressive therapy, provided that
the balance between toxicity and probability of cure has been discussed and
accepted by the patient.
Acute dysphagia is often considered of less concern due to its transient nature.
Nevertheless, it is a well recognized cause of malnutrition that leads to significant
morbidity, higher mortality, and decreased QoL [8,9]. Furthermore enhanced acute

toxicity may amplify late-effects such as fibrosis and lymphedema resulting in

increased dysphagia [10].
It is important that clinicians are aware of correlations between acute and late
toxicities, and are capable of recognizing patients at risk for severe acute
dysphagia, to reduce late dysphagia, prevent malnutrition, and provide aspiration,
with the goal of providing the proper supportive care for these patients.
Adequate diagnosis and care during the treatment may increase compliance with
the therapeutic protocol with a complete dose delivery of chemotherapy (CT) and
RT. With this aim, we presently reviewed the relevant literature in terms: 1)
definition, physiology and causes, 2) pretreatment evaluation of swallowing
disorders and predictive factors, and 3) evaluation and support measures during
treatment, and offer conclusions and recommendations.
Go to:

MATERIALS AND METHODS

A comprehensive literature review was finalized in May 2012. Electronic databases
(Medline, Embase, and CAB abstracts) and scientific societies meeting materials
(American Society of Clinical Oncology, Associazione Italiana Radioterapia
Oncologica, Associazione Italiana di Oncologia Cervico-Cefalica, American Head
and Neck Society, and European Society for Medical Oncology) were searched
with the date parameters of January 1990 through May 2012. The decision
concerning this range was made on the basis of the publication dates of the most
important research clinical trials, investigating dysphagia in acute and late
toxicities of HNC treatment.
Electronic search results were supplemented with hand searching of selected
reviews, expert consensus meeting notes, and reference lists from selected articles.
The literature search was limited to articles in English concerned with human
patients. Medical subject headings (MeSH) terms and keywords used in the search
were dysphagia, malnutrition, weight loss, head and neck cancer,
chemoradiotherapy, acute toxicity, and late toxicity.
Go to:

RESULTS
Definition, physiology, and causes
Dysphagia is defined as the difficulty or impossibility to swallow liquids, food, or
medication. Dysphagia can occur during the oropharyngeal or oesophageal phase
of swallowing. Normal swallowing is a complex and well-coordinated process,

which requires neural control regulated by interactions between cortical centres in

both hemispheres, the swallowing centre in the brainstem, cranial nerves (V, VII,
IX sensory, IX motor, X, and XII), and pharyngeal receptors for touch, pressure,
chemical stimuli, and water. Normal swallowing comprises four phases: oral
preparation, oral, pharyngeal, and oesophageal [11].
During the oral preparatory phase of swallowing, the food is ground and mixed
with saliva to form a bolus. In the oral phase, the bolus is transported to the
pharynx. The swallowing reflex is triggered during the pharyngeal phase, resulting
in closure of the larynx to prevent aspiration, contraction of the pharyngeal
constrictors from superior to inferior, laryngeal elevation and epiglottis inversion,
and relaxation of the crico-pharyngeus to allow the food bolus to pass into the
oesophagus. During the final phase, the peristalsis of the oesophageal muscles
results in movement of the bolus into the stomach. Deregulation in any of these
functions can result in dysphagia. Additionally, swallowing and neck movement
require that the pharyngeal structures and carotid sheath move easily relative to the
spine and prevertebral space. The pharynx is essentially a muscular tube suspended
from the skull base. The fat in the retropharyngeal and para-pharyngeal spaces
allow for this necessary movement and pharyngeal expansion as well [11].
Penetration is defined as the passage of material into the larynx that does not pass
below the vocal folds. The amount of material, depth of penetration, and whether
all or a portion is subsequently expelled are potentially critical variables and
deserve study, but are not part of the definition. Aspiration is defined as passage of
material below the level of the vocal folds [12].
Causes of dysphagia include different alterations of the swallowing process that
can interfere with physiological functions in each step of these described. Damage
at anatomical structures or neurological damage may hinder normal physiology.
Most common alterations include structural incontinence of the oral cavity;
incorrect movement of the supraglottic larynx, epiglottis, and vestibule; reduced
pharyngeal peristalsis; alterations of prevertebral space; and other muscular and
neurological dysfunctions. All these types of damage contribute differently and to
varying degrees to dysphagia after HNC treatment (Table 1) [4].

Table 1
Causes of damage: correlations with head and neck cancer treatment or neurologic
damage

Swallowing disorders may cause aspiration that is usually prevented by an intact

cough reflex. Aspiration causes can be divided to those occurring before, during,
and after swallowing (Table 2) [4]. The incidence of silent aspiration varies from
9% to 18.5% at diagnosis and from 22% to 60% after specific treatment [13-15].
Aspiration due to neurological causes typically occurs before or during
swallowing, while in HNC patients it occurs after swallowing due to the entry of
excessive residue into the larynx through damaged regions. Neurological and
structural impairment can cause distinctive swallowing problems.

Table 2
Aspiration in relation of timing of swallowing: pathophysiology
In HNC patients, structural impairment generally prevails even if both these
problems can be contemporaneous, as a consequence of structural damage
involving nerve or muscles or related to the consumption of certain medications.
Anticholinergic drugs, steroids, asthma medications, vasoconstrictors, or
expectorants can cause xerostomia. Antidepressants, anti-anxiety agents,
antipsychotic, sedatives, and hypnotic agents can depress the central nervous
system. Some antipsychotics may also cause extra-pyramidal effects with facial
and mouth dyskinesias. Penicillamine or antibiotics like aminoglycosides and
erythromycin may block the neuromuscular junction. Corticosteroids or lipid
lowering agents can cause drug-induced myopathy [16].
Pretreatment evaluation of swallowing disorders and predictive factors
Evaluation of swallowing disorders in nave HNC patients is complex and requires
a multi-team collaborative effort involving head and neck surgeons, speech
pathologists, radiation oncologists, medical oncologists, radiologists, and
nutritionists. All patients at risk should be screened by a multimetric model in
which more than one parameter indicates dysphagia. Murphy's trigger symptoms,
excessive chewing, drooling, and complaint of food sticking in the throat are
suggestive of dysphagia (Table 3) [17]. Of particular concern are symptoms that
indicate potential aspiration, including coughing or clearing the throat before,
during, or after eating. If patients develop any of these symptoms, an immediate
referral for assessment by a Speech Language Pathologist should be considered.
Patients with significant aspiration risk and those who need enteral/parenteral
nutrition should be identified and enrolled in a program that includes education and
swallowing therapy. Adequate and safe nutrition should also be guaranteed.
Patients with silent aspiration often subconsciously reduce their oral intake and

lose weight; this finding alone should lead to instrumental assessment [18]. Rosen
et al. [19] reported in a prospective study on newly diagnosed HNC patients that
experienced clinicians (otolaryngologists and speech pathologists) correctly
predicted only six of 11 patients who actually aspirated on videofluoroscopy. The
difficulty in predicting aspiration was attributed to the absence of the cough reflex
in some patients.

Table 3
Triggers for dysphagia evaluation
Instrumental assessment
Instrumental assessment of swallowing in HNC patients provides useful
information about both the structure and function of this mechanism. Two
procedures are usually performed: video-fluoroscopic modified barium swallow
(VMBS) and fiberoptic endoscopic evaluation (FEES).
VMBS is a video-fluoroscopic examination that allows evaluation of oral and
pharyngeal function by successive records of images, while FEES is a fiber-optic
endoscopic examination (which avoids radiation exposure) that allows an excellent
visualization of anatomy, including postsurgical or postradiation modifications or
lesions. Both VMBS and FEES identify disorders that impair swallowing, cause
aspiration, and increasing the risk for pneumonia. Additionally, they provide an
evaluation of a patient's ability to maintain nutrition and hydration. Standardized
protocols have been established for VMBS that test swallowing capacity using
contrast containing food boluses of varying sizes and consistencies, thus allowing a
Speech Language Pathologist to make dietary recommendations for patients with
impaired swallowing. If abnormalities are identified, various compensatory
measures including postural techniques, increased sensory input, and voluntary
swallowing manoeuvres can be assessed for efficacy [11].
The penetration-aspiration scale has been developed to allow objective reports of
penetration and aspiration events. The 8-point scale provides reliable quantification
of selected penetration and aspiration events observed during video-fluoroscopic
swallowing evaluations. Other systems can be used to specify the amount and
timing of penetration and aspiration events. These scoring systems do not
substitute for other perceptual measures of swallowing tested with VMBS and

FEES. However, the use of these scales permits a numeric quantification of

dysphagia, facilitating accurate communication among clinicians.
In clinical practice, FEES is more convenient and less expensive than VMBS, and
can be performed repeatedly [20]. Thus, a large number of dysphagic patients may
be evaluated with FEES, while VMBS may be used less frequently and in selected
cases. However, a prospective, randomized trial of 126 patients assigned to FEES
or VMBS demonstrated no advantage of either technique in predicting aspiration
pneumonia in patients with dysphagia [21]. Thus, the two instrumental assessments
seem to be equivalent and complementary. VMBS allows evaluations of the entire
upper digestive system including oral phase deficits, while FEES seems to be an
adequate test for evaluation of the pharyngeal phase of swallowing [22].
Instrumental examinations only assess the structures and dynamics of the
swallowing process, and do not assess the influence of the swallowing problems on
a patient's overall QoL (i.e., personal perception of well-being). HNC and its
treatment can affect both disease-specific health-related QoL (HRQoL), such as
salivary and swallowing functions, and the general domains of HRQoL, such as
physical, mental, and social health [8]. Recently, Langendijk et al. [22] advocated a
simple measure designated the total dysphagia risk score (TDRS) to predict
swallowing dysfunction after curative RT for HNC. TDRS is a summation of the
following risk points: T-classification (T3, 4 points; T4, 4 points), neck irradiation
(bilateral neck irradiation, 9 points), weight loss (1%-10%, 5 points; >10%, 7
points), primary tumour site (oropharynx, 7 points; nasopharynx, 9 points) and
treatment modality (accelerated RT, 6 points; concomitant CT, 5 points). The
authors also reported that this predictive model could also be adapted for acute
morbidity. In a retrospective study with 47 patients, Kowai et al. [23] observed
swallowing dysfunction (as Radiation Therapy Oncology Group [RTOG] grade 2
or higher) in 27 patients (57%;P<0.001). The cut-off value of the TDRS was set at
18 (sensitivity, 0.81; specificity, 0.85). Prediction of severe (grade 3) acute
swallowing dysfunction was similarly obtained. The authors concluded that the
TDRS is a useful tool to predict acute swallowing dysfunction induced by CRT for
HNC.
Despite the plethora of available indices for cancer in general, few measurement
tools are specific to HNC. Most of those HNC-specific tools measure QoL and few
measure the common comorbidities of speech and swallowing. As a result, there is
a gap of outcome measures specific to speech and swallowing that requires
addressing [24].
Van der Molen [14] conducted a systematic review of the literature and found only
a few studies combined VMBS examinations with QoL questionnaires. Some
authors showed the utility of monitoring dysphagia problems that afflict these
patients in their multidimensional aspects: pre- and posttreatment dysfunction,
objective instrumental and clinical (symptom and sign) rated-assessment, and

subjective clinician-rated and patient-rated assessments of swallowing

abnormalities (European Organisation for Research and Treatment of Cancer
Quality of Life Questionnaire Core 30 [EORTC QLQ-C30] and the EORTC QLQH&N35) [13,24]. Several pretreatment functional problems identified either by
instrumental assessment (e.g., postswallowing residue) or clinician assessment is
not perceived by patients; 30% have silent penetration/aspiration [14].
Recently Christianen et al. [6] eported a large multicentre prospective cohort study
that evaluated toxicity and HRQoL prior to, during, and at regular intervals after
curative CRT. The authors investigated dose volume histogram parameters and
pretreatment factors to establish those predictive of radiation-induced swallowing
dysfunction.
Factors predictive of dysphagia
T and N stage, primary site, type of treatment, extension of treated region (volume
of tissue and anatomic structures), patient characteristics (baseline swallowing
function, performance status [PS], smoking and alcohol abuse, age, lean mass,
gender) predict the risk of acute and late dysphagia.
All treatment modalities, whether involving surgery or organ sparing protocols,
and CRT result in swallowing problems along with aspiration. Therefore, we can
classify factors predictive of dysphagia as patient-related, tumor-related, and
treatment-related [18,25]. Patient characteristics such as baseline swallowing
function, PS, smoking and alcohol abuse, age, lean mass, and gender predict the
risk of dysphagia [13]. Advanced T and N stage are associated with worst
swallowing impairment [22].
Whether a different primary tumor site is better related with frequency and severity
of acute and late dysphagia is contentious. Aspiration is most frequent in
hypopharynx or larynx cancer patients before treatment; the worst base-line
function could account for higher rate of swallow impairment in this subset of
patients [26].
Logemann [27] in a consecutive series of 53 VMBS reported that pressure
generation during swallowing and airway protection are the most frequent
disorders observed (reduced tongue base retraction and reduced tongue strength). A
more frequent reduction in tongue base movement was described in patients with
oropharynx and larynx cancer. Since the tongue base lies between the oropharynx
and larynx, it is likely that the tongue base receives the maximal radiation dose
when these areas are irradiated. However, the study was limited by the small
number of patients for each site of the primary tumor.
In a similar study, Frowen et al. [28] found that patients with hypopharyngeal
tumors had significantly worse swallowing, compared with either oropharyngeal or

laryngeal tumors, for all instrumental measures (P=0.001 to P=0.042), except the
penetration/aspiration of liquids. At 6 months posttreatment, patients with
hypopharyngeal tumors were still experiencing a moderatesevere or moderate
degree of activity limitation. For 50% of these patients, enteral nutrition was still
required.
Patients with oropharyngeal tumors reportedly have significantly worse activity
limitation for semisolids than patients with laryngeal tumours (P=0.01),
particularly at 3 months posttreatment (43% for mild limitation vs. 73 for no
limitation) [29]. After 6 months these differences were reduced (74% vs. 86%)
with only a transient risk of airway penetration. Moreover, patients with laryngeal
cancer are thought to be less at risk for weight loss and reduced food intake than
patients with other primary HNC [29].
The type of treatment (organ anatomic preservation vs. surgery, demolitive vs.
partial surgery, concurrent CRT vs. RT) and the extension of treated region
(volume of tissue and anatomic structures) results in different severity of this
sequelae [30]. Shune et al. [26] recently reported the association between severity
of dysphagia and survival defining risk factors: advanced stage, older age, female
sex and hypo-pharyngeal tumors. Table 4 summarizes three causes that, in our
opinion, most influence dysphagia [4,15,18,27,31].

Table 4
Treatment related dysphagia
Dysphagia after surgery
Surgery in HNC patients may cause dysphagia by damage/resection of muscular,
bony, cartilaginous, or nervous structures (swallowing anatomical structures and
neurological structure) as well as by neck fascia removal. The severity of the
swallowing deficit is dependent on the size and location of the lesion, and the
degree and extent of surgical resection [32]. However, Miller and Groher [33]
proposed that the removal of less than 50% of a structure involved with
swallowing will not interfere or seriously influence swallowing function.
The importance of the anatomical region of excision has been highlighted by
several reports. The size of the lesion excised is less prognostic than the excised
area. Therefore, dysphagia can be accurately predicted for some surgeries, such as
the base of the tongue and arytenoid cartilage resections [34]. Even though the

introduction of robotic surgery has improved outcomes, several reconstructions

achieve an aesthetic, but not functional, objective (tissue flaps have no motor
function resulting in the loss of propulsive force). Surgical complications including
nerve function interruption may affect swallowing function. Furthermore, neck
dissection significantly increases aspiration as well as gastrostomy tube
dependence [32]. Edema, pain, scarring, and nerve injury due to neck dissection
are all potential causes in the pathogenesis of swallowing dysfunction [11].
Dysphagia after RT or CRT
Despite the fact that modern RT protocols are designed to spare normal tissue and
preserve structure and function, dysphagia remains a potentially life-threatening
occurrence in HNC patients treated with RT or CRT. Irradiation of swallowing
structures and altered dose fractionation contributes to worsened dysphagia.
Eisbruch et al. [31] identified dysphagia/aspiration-related structures (DARSs)
whose treatment-related damage can lead to swallowing dysfunction. DARSs
include the pharyngeal constrictor muscles (PCM), supraglottic larynx, and glottic
larynx.
Bilateral neck RT has been identified as a prognostic factor for dysphagia and
weight loss in early stage laryngeal cancer (T1/T2), although it is difficult to
discern whether a larger tumor (high stage) or treatment protocols per se most
affect dysphagia. Langius et al. [29] reported that RT on cervical level II-IV lymph
nodes has the most negative effect, likely due to irradiation of major salivary
glands with consequently xerostomia, acute dysphagia, and weight loss.
Accelerated RT can worsen acute dysphagia compared to conventional
fractionation, as shown in the analysis of data from the DAHANCA trial [35].
Severe dysphagia, defined as liquid food only or worse, and no intake per os (grade
3 or 4) occurred in 47% and 38% of patients receiving accelerated or conventional
RT, respectively (P=0.001). Significant independent factors for severe acute
dysphagia were T3-T4 tumors, N-positive and non-glottic cancer, age >62 years,
baseline dysphagia >0, and accelerated RT. The use of intensity-modulated
radiation therapy (IMRT) minimizes radiation to DARS resulting in improved
swallowing outcomes. The main gain in dysphagia-sparing IMRT is obtained when
medial retropharyngeal nodes are spared, assuming they are at low risk for failure
[31].
Levendag et al. [36] in a cohort of 81 patients demonstrated a steep dose-effect
relationship with an increase in the probability of dysphagia of 19% with every
additional 10 Gy after 55 Gy for pharyngeal superior constrictor muscle and mean
constrictor muscle. The volume of RT-treated swallowing structures is a prognostic
factor. In the Trans Tasman Radiation Oncology Group (TROG) 91.01 trial, the
volume of irradiated pharynx (which included the mucosa and underlying
pharyngeal constrictor muscles) was correlated to the probability of requiring
enteral feeding [37].

A correlation between food consistency and anatomical cause of dysphagia was

reported by Christianen et al. [6]. Damage of the superior PCM is responsible for
solid food dysphagia. Laryngeal elevation and cricopharyngeal opening is
necessary for pharyngeal clearance, which may lead to patient self-restriction in the
amount and viscosity of food taken. In combination with inadequate airway closure
at the supraglottic larynx, this could lead to aspiration. This knowledge permits a
correlation among some unexplained weight loss in early stage HNC and the
specific swallowing structure dysfunction.
Although CRT improves locoregional control and overall survival, and allows for
organ preservation, it increases toxicities compared with RT alone [4]. The most
common acute grade 3 to 4 complications (leucopenia, anemia, mucositis, and
dysphagia) are increased 14% to 43% over RT [38]. CRT often results in higher
rates of swallowing difficulty. Furthermore, side-effects like nausea, vomiting,
neutropenia, generalized weakness, and fatigue can occur in acute dysphagia and
malnutrition. All patients receiving CRT report some grade of mucositis. Drugs
commonly used in CRT are anti-metabolites, taxans and platin salts. Antimetabolites like methotrexate and 5-fluorouracil seem to be the drugs that are most
associated with mucositis. Taxans are associated with allergy and peripheral
neurotoxicity, while platins are more associated with hematological toxicities and
dysgeusia [38,39].
Concomitant CT emerged as the strongest independent factor correlated with acute
morbidity in several studies [17,38,39]. When CT is associated with RT, the critical
dose to swallowing structure is lower. These differences seem related to acute
mucositis and its consequential effect on pharyngeal tissue. Chemoradiation
regimens that do not differ markedly in the rate and severity of the acute mucositis
seem to cause similar types and rates of swallowing abnormalities than RT alone
[15]. In a population of platinum-based CRT patients, the 5-year actuarial rates of
overall late RTOG/EORTC grade 3 and grade 4 toxicity were 52% and 25%,
respectively. Radiologic evaluation after a median follow-up of 44 months
demonstrated impaired swallowing in 57% of the patients, including 23% with
silent aspiration. Subjective assessment using a systematic scoring system
indicated normalcy of diet in only 15.6% of the patients [15].
Data from randomized trials have added further evidence. In the RTOG 91-11
randomized trial, the incidence of severe (grade 3, 4) stomatitis and dysphagia
increased with CT, respectively, from 24% and 19% (RT alone) to 43% and 35%
(concomitant CRT), although skin effects were not altered (7% vs. 9%) [40]. In the
EORTC 22931 trial, the incidence of severe functional mucosal effects increased
with CRT from 21% to 41% [41]. In the RTOG 95-01 trial, concomitant CT had an
adverse effect on severe mucositis (from 18% to 30%) and dysphagia (from 15% to
25%), but not on skin morbidity (10% vs. 7%) [42]. In a nonrandomized
comparison of patients treated at a single centre in prospective phase I and II trials
of concomitant CT-IMRT (n=85) and the phase III trial of IMRT vs. conventional

RT (PARSPORT) (n=82), G3 dysphagia was recorded prospectively [43]. Feng et

al. [3] recently showed benefits from efforts to spare the swallowing structures in
chemo-IMRT treated patients reporting a dose-volume aspiration effect for the
PCM. Benefit to maximized superior constrictors was involved. The dose-volume
effect relationships for the swallowing structures may depend on the intensity of
the CRT regimen. Strictures were not observed in patients receiving mean
pharyngeal constrictors doses exceeding 66 Gy. These relationships support the
hypothesis that a lower dose to the swallowing structures may reduce the
prevalence and severity of dysphagia. However, the available data do not yet prove
this hypothesis because they do not establish a cause-effect association [3].
Additionally, it is not known if the combination of epidermal growth factor
receptor (EGFR) inhibitors and RT results in lower rates of swallowing disability.
In 2006, Bonner et al. [44] published the results of a phase III trial that showed the
efficacy and safety of the addition of cetuximab, a monoclonal antibody developed
to inhibit the EGFR pathway. Cetuximab enhanced the effects of RT and improved
survival at 5 years in patients with advanced HNC. Skin toxicity was the most
frequent side effect of the cetuximab-RT regimen. However, more severe mucositis
and acute dysphagia than occurring with RT alone has been reported. Table
5 provides a summary of the most impressive trials evaluating dysphagia during
HNC treatment [14,30,31,45-52].

Table 5
Dysphagia evaluation during head and neck cancer treatment
Evaluation and support measures during treatment
Dysphagia can directly result in decreased eating, malnutrition, and weight loss
[26]. Severe unintentional weight loss occurs in 5% to 71% of patients with HNC
and averages 6% to 12% of pretreatment body weight [10]. Weight loss can be
attributed to energy imbalance consisted of decreased energy intake from reduced
food consumption and/or increased energy expenditure from altered metabolic rate.
Weight loss is associated with a significantly lower survival rate and is an
independent predictor for mortality in patients with stage III and IV tumors. Body
weight loss also causes RT dose problems. The risk of delivering an inadequate
radiation dose to the target volume and critical structures may arise if coordinated
re-planning is not performed during the course of the therapy, especially when

using highly conformal methods [23]. Nutrition in HNC patients with a high risk of
dysphagia is still debatable. On the one hand, systematic use of the percutaneous
endoscopic gastrostomy tube (PEG) may avoid weight loss [53]. On the other
hand, it may expose a significant proportion of patients to needless cost and risks
of tube placement [54]. Furthermore, the potential benefit from a wait-and-see
procedure with PEG insertion is supported by the findings of complications and
prolonged dysphagia in patients whose treatment utilizes a PEG. In patients that do
have a high risk of weight loss a short period of parenteral nutrition may be
adequate [55]. Enteral nutritional treatment can be indicated when weight loss
exceeds 5% of the patient initial weight [56], whereas other authors advocate that
enteral therapy should begin before RT treatment [57]. It is unclear whether dietary
counselling or nutritional support actually increases lean mass in HNC with
dysphagia, with dietician evaluation at baseline recommended [58,59].
A secondary analysis of RTOG 90-03 reported that nutritional support before RT is
associated with poorer treatment outcome [60]. Indeed, patients on nutritional
support delivered before treatment had significantly less weight loss and grade 3
mucositis. However, surprisingly they had worse 5-year loco-regional control
(LRC). These conclusions did not come from a pre-established analysis, limiting
their power.
Prevention and treatment of mucositis and swallowing-induced pain are areas of
great interest, but a golden standard is still not available. In a majority of patients,
pain (tumor- and treatment-related) can be severe and require major analgesics.
Both pain and opioids can contribute to decreased dietary intake and the latter
increases gastro-intestinal motility alterations [61].
A recent Cochrane review [62] reported that retrospective studies have revealed
complications including laryngeal irritation and persistent gastro-oesophageal
reflux in patients fed with a nasal gastric tube (NGT). Furthermore, use of a NGT
may increase patient discomfort, and increase the risk of tube displacement and
blockage compared to use of a PEG. PEG feeding may be the preferred method in
patients with radiation-induced oral and esophageal mucositis. Potential
advantages of PEG over NGT include enhanced mobility, improved QoL, and
consumption of higher caloric food. According to Nugent et al. [62], 2010 PEG
should be recommend to all patients before treatment, in view of its beneficial
effect on QoL. Conversely, prolonged enteral nutrition status is directly correlated
with worse swallowing outcomes and increased risk for dysphagia. Atrophy of
pharyngeal and tongue-base musculature and increased pharyngeal fibrosis can
result both from general non-use of swallowing musculature and from a marked
decrease in patient swallowing (volitional or spontaneous) [26].
We suggest elective use of PEG to reduce swallowing difficulties, as secondary
consequences of prolonged enteral status. Timely identification of the subgroup of
patients with dysphagia or with a risk of developing severe dysphagia that will

require a PEG before or during treatment is critical to maximize benefits [63]. The
TDRS may serve as an index to enable selection of appropriate candidates for
prophylactic PEG placement [15]. However, Mangar et al. [64] showed that some
clinical parameters, such as tumor site, PS 2-3, older age, low body mass index,
and serum albumin predict nutritional deficit. Treatment for oropharyngeal
dysphagia is typically quite different than that for esophageal dysfunction. While
there are some drugs and surgical procedures available to improve function of the
esophageal swallowing process, in the pharynx there are not the same possibilities
for part of the process. Rehabilitation includes behavioural changes, such as
posture, sensory stimulations, swallow manoeuvres, voluntary controls exerted
over the swallow, and/or changes in diet [11].
Emerging data indicate that early intervention with swallowing exercises may
improve dysphagia, whereas delayed swallowing therapy achieves only minor
benefit [65]. Other data suggest that function at 6 months predicts long-term
function [66]. It therefore seems reasonable to aim for maximal swallowing
recovery by 6 months post-CRT, but randomized trials are necessary to confirm
these findings. Pharmacologic interventions, such as amifostine and keratinocyte
growth factor, may reduce toxicity and are showing promise, but are of secondary
importance to good radiation technique and support of the health care team [37].
HRQoL questionnaires evaluating dysphagia in the literature include the SWALQoL, the MD Anderson Dysphagia Inventory, and the Deglutition Handicap Index
[66,67].
Go to:

CONCLUSIONS
Dysphagia is an increasingly recognized problem in the treatment of HNC. It
affects QoL and survival. To ensure adequate therapies for RT and/or CRT
candidates, a pretreatment evaluation of swallowing function and nutritional status
is needed. A new standard of multidisciplinary approach in HNC should include
routine diagnostic swallowing assessments and therapeutic interventions before,
during, and after therapy. Data collected in the present systematic literature review
indicate that surgery and RT or CRT can impair swallowing. Swallowing and neck
movement require that pharyngeal structures, visceral fascia, and sheath move
easily relative to the spine and prevertebral space. Surgical or RT fibrosis and
anatomic concerns hinder this necessary movement and pharyngeal expansion as
well. Dysphagia has been not adequately considered during HNC treatment plans.
However, in the past several years there has been a growing interest around the
major common sequelae of surgery and CRT. Understanding of the
pathophysiology through the identification of DARS (muscles, glottic and
supraglottic larynx, nerves) may allow radiation oncologists to reduce the dose
delivered to the swallowing organs. At the same time, ear/nose/throat specialists
should avoid aggressive surgery when it is not needed to improve survival

outcomes. Dysphagia evaluation should help physicians to determine appropriate

cancer therapy, increase patient compliance, and provide adequate posttreatment
care. Immediate treatment of dysphagia will increase adherence to treatment
protocol, while nutritional support will avoid critical weight loss. Additionally,
awareness of dysphagia will also help pain management. For instance, starting
intensive rehabilitation with pretreatment swallowing exercises improves
posttreatment swallowing function. In Table 5, we summarize some helpful
recommendations for early diagnosis and as a guide for the multidisciplinary team.
A multi-parameter assessment of dysphagia that considers the objectiveinstrumental examinations (e.g., residue research), patient-rated assessment (e.g.,
pain), and clinician-rated assessment (e.g., weight loss) of swallowing problems
can allow for a better diagnosis, based on a better understanding of symptoms. This
allows, on one hand, a proper prediction of late dysphagia and, on the other hand,
accurate supporting care during the treatment. The diffusion of an adequate
HRQoL questionnaire could further contribute to enhanced information from the
patients' point of view.
Go to:

ACKNOWLEDGEMENTS
Laurence Preston revised the English text of the manuscript.
Go to:

Footnotes
No potential conflict of interests relevant to this article was reported.
Go to:

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Articles from Clinical and Experimental Otorhinolaryngology are provided
here courtesy of Korean Society of Otorhinolaryngology - Head and
Neck Surgery

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