Introduction

The favorable oncologic outcomes of organ preservation therapy for individuals with head and neck cancer are well-established. Increasingly, individuals with head and neck cancer are being treated with organ preservation approaches rather than surgery. Nonsurgical approaches include:

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  Radiation therapy alone

  
  
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  Neoadjuvant chemotherapy with radiation

  
  
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  Induction chemotherapy

  
  
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  Concurrent chemoradiation treatment.

Preservation of structure afforded by these management options, unfortunately, does not correlate with preservation of function. Posttreatment dysphagia, dysphonia, and related complications are described in multiple sources. Increased radiation dose to a larger volume of the pharyngeal constrictors is associated with more severe dysphagia, resulting in diminished quality of life after treatment. In this article, evaluation and treatment of dysphagia in individuals receiving chemoradiation and radiation to treat their head and neck cancer at Johns Hopkins Hospital are presented. Pretreatment and posttreatment speech-language pathology evaluation is described, including specific swallowing deficits and interventions to address these deficits. Evidence regarding the role of oral motor exercises, management of trismus, treatment of xerostomia, and the influence of oral hygiene are reviewed. In addition, clinical outcomes of patients whose tumors are human papillomavirus (HPV)-related and HPV-nonrelated are compared.

Videofluoroscopic findings in individuals treated with chemoradiation and/or radiation therapy

Dysphagia in patients treated with chemoradiation and radiation is characterized by a multiplicity of deficits. Several investigators have reported objective findings from videofluoroscopic swallowing studies (VFSS). Similar findings have been documented by the investigators. For example, Lazarus and colleagues conducted VFSS in nine patients with head and neck cancer who were treated with radiation therapy and adjuvant chemotherapy. They reported aspiration, reduced posterior tongue base retraction, reduced laryngeal elevation, and need for multiple swallows to clear pharyngeal residue. Carrara-de Angelis and colleagues conducted VFSS to assess 14 patients who were treated with concomitant paclitaxel, cisplatin, and radiotherapy for advanced squamous cell carcinoma of the larynx or hypopharynx. Findings included

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  Reduced bolus formation (n = 13)

  
  
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  Reduced bolus propulsion (n = 12)

  
  
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  Oral stasis (n = 13)

  
  
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  Pharyngeal stasis (n = 12)

  
  
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  Reduced laryngeal elevation (n = 5).

Patients were rated using the Penetration-Aspiration Scale :

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  There was no penetration or aspiration in three patients

  
  
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  Penetration occurred in six patients

  
  
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  Aspiration occurred in five patients.

Most patients received swallowing therapy after the VFSS. At follow-up (mean 20 months, range 10–32 months)

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  7 of the 14 patients had normal swallowing

  
  
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  1 patient was still using a gastrostomy feeding tube.

Lazarus assessed lingual strength and conducted VFSS in 12 patients who were treated with radiotherapy:

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  All subjects demonstrated tongue strength impairment and had reduced base-of-tongue retraction on the video studies.

Pretreatment and posttreatment swallowing function has been described in multiple sources:

• •
  

  Eisbruch and colleagues conducted VFSS of patients with locally advanced head and neck cancer before and after chemoradiation therapy. Swallowing function was not normal before treatment, which was most likely due to location of the tumors in the upper digestive tract. Furthermore, multiple swallowing decompensations were identified after treatment in the absence of bulky tumor; six patients developed pneumonia that was attributed to aspiration.

  
  
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  Pauloski and colleagues performed VFSS on 352 patients with head and neck cancer who were to receive either primary surgery or primary radiation therapy with or without concurrent chemotherapy. Similar to Eisbruch and colleagues, their findings showed that the presence of a tumor in the upper aerodigestive track can disrupt normal swallowing. Patients with oral cavity and pharyngeal lesions tended to have poorer swallow function than those with laryngeal lesions. Patients with laryngeal tumors had significantly shorter oral transit times, less oral residue, shorter pharyngeal transit times, and longer cricopharyngeal opening than did those with either oral or pharyngeal lesions.

  
  
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  Graner and colleagues evaluated swallowing in 11 patients with advanced head and neck cancer before and after completion of intraarterial chemoradiation and planned neck dissection. On the pretreatment VFSS, swallow function was impaired in 9 of 11 patients, with aspiration seen in 3 patients. Following treatment, aspiration was observed in 7 patients. Tongue base retraction, reduced laryngeal elevation, and increased laryngeal vestibule penetration of thick liquid were all statistically significantly worse after treatment. After treatment, soft diets were required and ability to eat in public was restricted.

  
  
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  Kotz and colleagues also conducted before and after chemoradiation and chemoradiation VFSS in patients with advanced-stage head and neck cancer. On the posttreatment studies, all patients had reduced contact between base of tongue and posterior pharyngeal wall. Most patients also had reduced laryngeal elevation and compromised laryngeal vestibule closure.

  
  
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  Logemann and colleagues evaluated 53 patients with advanced head and neck cancer before and 3 months after completing chemoradiation treatment. Findings were reported by site of the primary cancer. Before treatment, 28% of the patients with laryngeal cancer had gastrostomy tubes and 14% were aspirating. Three months after treatment, the laryngeal cancer group had the highest frequency of reduced base-of-tongue retraction, reduced anterior-posterior tongue movement, delayed pharyngeal swallow, reduced laryngeal elevation, and reduced cricopharyngeal opening compared with the nasopharyngeal, oropharyngeal, hypopharyngeal, and unknown primary cancer groups. Furthermore, half of these patients continued to use their gastrostomy feeding tubes posttreatment and 7% continued to aspirate.

Videofluoroscopic findings in individuals treated with chemoradiation and/or radiation therapy

Dysphagia in patients treated with chemoradiation and radiation is characterized by a multiplicity of deficits. Several investigators have reported objective findings from videofluoroscopic swallowing studies (VFSS). Similar findings have been documented by the investigators. For example, Lazarus and colleagues conducted VFSS in nine patients with head and neck cancer who were treated with radiation therapy and adjuvant chemotherapy. They reported aspiration, reduced posterior tongue base retraction, reduced laryngeal elevation, and need for multiple swallows to clear pharyngeal residue. Carrara-de Angelis and colleagues conducted VFSS to assess 14 patients who were treated with concomitant paclitaxel, cisplatin, and radiotherapy for advanced squamous cell carcinoma of the larynx or hypopharynx. Findings included

• •
  

  Reduced bolus formation (n = 13)

  
  
• •
  

  Reduced bolus propulsion (n = 12)

  
  
• •
  

  Oral stasis (n = 13)

  
  
• •
  

  Pharyngeal stasis (n = 12)

  
  
• •
  

  Reduced laryngeal elevation (n = 5).

Patients were rated using the Penetration-Aspiration Scale :

• •
  

  There was no penetration or aspiration in three patients

  
  
• •
  

  Penetration occurred in six patients

  
  
• •
  

  Aspiration occurred in five patients.

Most patients received swallowing therapy after the VFSS. At follow-up (mean 20 months, range 10–32 months)

• •
  

  7 of the 14 patients had normal swallowing

  
  
• •
  

  1 patient was still using a gastrostomy feeding tube.

Lazarus assessed lingual strength and conducted VFSS in 12 patients who were treated with radiotherapy:

• •
  

  All subjects demonstrated tongue strength impairment and had reduced base-of-tongue retraction on the video studies.

Pretreatment and posttreatment swallowing function has been described in multiple sources:

• •
  

  Eisbruch and colleagues conducted VFSS of patients with locally advanced head and neck cancer before and after chemoradiation therapy. Swallowing function was not normal before treatment, which was most likely due to location of the tumors in the upper digestive tract. Furthermore, multiple swallowing decompensations were identified after treatment in the absence of bulky tumor; six patients developed pneumonia that was attributed to aspiration.

  
  
• •
  

  Pauloski and colleagues performed VFSS on 352 patients with head and neck cancer who were to receive either primary surgery or primary radiation therapy with or without concurrent chemotherapy. Similar to Eisbruch and colleagues, their findings showed that the presence of a tumor in the upper aerodigestive track can disrupt normal swallowing. Patients with oral cavity and pharyngeal lesions tended to have poorer swallow function than those with laryngeal lesions. Patients with laryngeal tumors had significantly shorter oral transit times, less oral residue, shorter pharyngeal transit times, and longer cricopharyngeal opening than did those with either oral or pharyngeal lesions.

  
  
• •
  

  Graner and colleagues evaluated swallowing in 11 patients with advanced head and neck cancer before and after completion of intraarterial chemoradiation and planned neck dissection. On the pretreatment VFSS, swallow function was impaired in 9 of 11 patients, with aspiration seen in 3 patients. Following treatment, aspiration was observed in 7 patients. Tongue base retraction, reduced laryngeal elevation, and increased laryngeal vestibule penetration of thick liquid were all statistically significantly worse after treatment. After treatment, soft diets were required and ability to eat in public was restricted.

  
  
• •
  

  Kotz and colleagues also conducted before and after chemoradiation and chemoradiation VFSS in patients with advanced-stage head and neck cancer. On the posttreatment studies, all patients had reduced contact between base of tongue and posterior pharyngeal wall. Most patients also had reduced laryngeal elevation and compromised laryngeal vestibule closure.

  
  
• •
  

  Logemann and colleagues evaluated 53 patients with advanced head and neck cancer before and 3 months after completing chemoradiation treatment. Findings were reported by site of the primary cancer. Before treatment, 28% of the patients with laryngeal cancer had gastrostomy tubes and 14% were aspirating. Three months after treatment, the laryngeal cancer group had the highest frequency of reduced base-of-tongue retraction, reduced anterior-posterior tongue movement, delayed pharyngeal swallow, reduced laryngeal elevation, and reduced cricopharyngeal opening compared with the nasopharyngeal, oropharyngeal, hypopharyngeal, and unknown primary cancer groups. Furthermore, half of these patients continued to use their gastrostomy feeding tubes posttreatment and 7% continued to aspirate.

Functional outcomes in individuals treated with chemoradiation and/or radiation therapy

Murry and colleagues evaluated quality of life and swallowing in 58 patients who were treated with chemoradiation:

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  Swallowing status was decreased during and immediately after treatment compared with pretreatment levels.

  
  
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  At the 6-month evaluation, quality of life returned to pretreatment levels, but swallowing status remained slightly below baseline.

Newman and colleagues described eating changes and weight loss in 47 individuals with advanced head and neck cancer treated with an intraarterial-administered chemoradiation protocol (radiation plus cisplatin [RADPLAT]):

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  Subjects lost 10% of their pretreatment weight and had deterioration in eating ability over the course of treatment.

  
  
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  At 18 months posttreatment, six patients still required percutaneous endoscopic gastrostomy (PEG) tubes and 34 reported normal or near-normal eating ability.

  
  
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  In a follow up study, intraarterial (RADPLAT) and intravenous-administered chemoradiation patients did not differ significantly on most swallow outcome measures at 1 month posttreatment, although there was significantly less aspiration on small bolus volumes in the RADPLAT group.

Gillespie and colleagues surveyed 22 patients with head and neck cancer who were treated with surgery followed by postoperative radiation and 18 treated with chemoradiation regarding quality of life:

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  Patients who received chemoradiation for oropharyngeal primaries demonstrated significantly better scores on the emotional and functional scales on the MD Anderson Dysphagia Inventory than did patients who underwent surgery followed by radiation therapy.

  
  
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  In contrast, there were no significant differences in subscale score for the surgery or radiation and chemoradiation groups for laryngeal or hypopharyngeal cancer sites.

Mowery and colleagues assessed quality of life in 17 patients with oropharyngeal cancer and 14 patients with laryngeal cancer status after chemoradiation. Mean time from completion of chemoradiation to assessment was 11 months:

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  Patients with oropharyngeal cancer reported diminished saliva significantly more often than the patients with laryngeal cancer.

  
  
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  Both groups reported difficulty with swallowing, chewing, and taste. Swallowing difficulties were attributed to tissue edema, friability, and fibrosis.

  
  
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  Nine of the patients with 14 laryngeal cancer and 6 of the 17 patients with oropharyngeal cancer rated quality of life as “good” or better.

Goguen and colleagues periodically assessed the swallowing status of 54 patients with head and neck cancer who received chemoradiation:

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  All patients developed dysphagia and had weight loss.

  
  
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  At 1 year follow-up, 80% were taking a soft diet and 81% had their gastrostomy feeding tube removed.

  
  
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  At 2 years posttreatment, 97% were taking a soft diet and 90% had their gastrostomy feeding tube removed, highlighting the need for long term follow-up.

Iatrogenic complications

Several side-effects associated with radiotherapy and chemotherapy have implications for swallowing. A primary complication of chemotherapy is mucositis, which can persist for weeks following completion of treatment, causing oral and pharyngeal tenderness and pain as well as sensitivity to temperature and spicy or acidic foods. Complications associated with radiotherapy can be acute or late onset and include

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  Mucositis

  
  
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  Candidiasis

  
  
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  Dysgeusia

  
  
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  Dental caries

  
  
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  Osteoradionecrosis

  
  
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  Soft tissue necrosis

  
  
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  Xerostomia.

Intensity-modulated radiation therapy provides a highly conformal dose distribution around tumor targets and potentially spares normal mucosa and salivary glands. Medications may also be used either to protect salivary glands or to improve salivary flow. Dentifrices can be used to ameliorate dry mouth. Patients should be counseled to maintain some degree of oral intake during and after treatment to avoid stricture formation.