Clinical Decision Making with Head and

Neck Cancer Patients with Dysphagia

Heather Starmer, M.A., CCC-SLP, BCS-S1,2 and
Jeffrey Edwards, M.S., CCC-SLP3

ABSTRACT

Dysphagia is a common challenge faced by patients with

head and neck cancer. Management of these patients is quite distinct
from many other dysphagia etiologies due to the nature of surgical

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removal of organs critical to swallowing, the ability to provide
preventative therapies, and the variable risk for complications related
to dysphagia. Thus, clinicians providing care to the head and neck
cancer population need to understand these differences when
employing clinical decision making. In addition, changes in the
demographics of head and neck cancer, related predominantly to
the epidemic of oropharyngeal cancer associated with the human
papillomavirus, have further transformed both the types of patients
and the types of treatments offered. These epidemiologic factors
further complicate the decision-making process for clinicians. This
article provides a framework for decision making in the surgical and
nonsurgical patient with head and neck cancer.

KEYWORDS: dysphagia, head and neck cancer, radiation therapy,

radiation-associated dysphagia, rehabilitation, swallowing therapy

Learning Outcomes: As a result of this activity, the reader will be able to (1) discuss how patients with head
and neck cancer differ from other populations with dysphagia; (2) apply critical thinking in selecting appropriate
assessment tools for evaluating dysphagia in patients with head and neck cancer; and (3) implement a risk-
stratified decision-making schema for determining when patients with head and neck cancer should receive a
feeding tube.

1
Department of Otolaryngology – Head and Neck Surgery, Clinical Decision Making in Dysphagia; Guest Editors,
Stanford University, Palo Alto, California; 2Head and Neck Gary H. McCullough, Ph.D., CCC-SLP and Balaji
Speech and Swallowing Rehabilitation, Stanford Cancer Rangarathnam, Ph.D., CCC-SLP.
Center, Palo Alto, California; 3Clinical Speech-Language Semin Speech Lang 2019;40:213–226. Copyright
Pathologist, Stanford Cancer Center, Palo Alto, California. # 2019 by Thieme Medical Publishers, Inc., 333 Seventh
Address for correspondence: Heather Starmer, M.A., Avenue, New York, NY 10001, USA. Tel: +1(212) 584-
CCC-SLP, BCS-S, Department of Otolaryngology – 4662.
Head and Neck Surgery, Stanford University, 900 Blake DOI: https://doi.org/10.1055/s-0039-1688979.
Wilbur Drive, Suite 3025, Palo Alto, CA 94305 ISSN 0734-0478.
(e-mail: [email protected]).
213
214 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 40, NUMBER 3 2019

T he management of patients with head lowing, early involvement of the SLP allows for a
and neck cancer (HNC) has remarkably chan- baseline functional assessment with instrumen-
ged in the last decade and a half, keeping in line tation whenever indicated, establishment of
with the biological and epidemiological nature functional outcome measures, intervention,
of HNC. Along with these changing disease and patient education before, during, and after
trends, de-escalation approaches to treatment, treatment based on a patient’s needs. As such, an
supported by technological advances in surgi- SLP’s involvement throughout the continuum
cal/medical treatments (e.g., intensity modula- of patient care promotes best functional out-
ted radiation therapy, transoral robotic-assisted comes and best practices in HNC.14,15
surgery), have improved functional outco- The nature of dysphagia in HNC differs
mes.1,2 Historically, prognosis with HNC was from other dysphagia etiologies (e.g., stroke,
poor due to a history of heavy alcohol and dementia, traumatic brain injury) as concomi-
tobacco use. Treatments often involved radical tant cognitive-linguistic impairments, which
surgical resection with significant functional may otherwise interfere with dysphagia treat-
morbidity, and wide-field radiotherapy with ment approaches, are less-often encountered in
significant acute and late toxicities to critical this setting. Patients with HNC-related dysp-
structures for speech and swallowing.3,4 While

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hagia are unique in that they are usually neuro-
alcohol- and tobacco-associated cancers have typical at onset, often present with functional
declined in the United States, the incidence of swallowing capacity—or at least adequate func-
HPV-related cancers of the head and neck tional reserve at baseline, and traditionally pre-
continue to rise.5 These patients are younger, sent with lower risk of pulmonary sequelae
healthier, and do not have the same alcohol- related to aspiration.16 Thus, clinicians provi-
and tobacco- related risks seen in prior genera- ding care to patients with HNC need to consider
tions and are more likely to be cured from how to alter a treatment approach that necessa-
treatment.6,7 As a result, these patients have rily may be more liberal, and in most cases more
different expectations of survivorship following proactive, than with other diagnostic groups.
their treatment, including the need to resume Management approaches to dysphagia in
typical vocational, social, and family responsi- the HNC setting can be organized into domains
bilities and retain an acceptable quality of life— of education and counseling, functional preser-
for many more years than historically observed vation, functional compensation, and functional
in the HNC population.8 Given the increased restoration (see Table 1). Since many patients
life expectancy for many of these patients with HNC will encounter functional loss secon-
compared with previous generations, simply dary to their oncological treatments, proper
surviving is an inadequate outcome. As such, education and counseling is critical to ensure
these patients require knowledgeable swallo- patients have realistic expectations of their reco-
wing rehabilitation specialists in addition to very and a thorough understanding of the life
skilled radiation, medical, and surgical oncolo- impact that may occur with respect to degluti-
gists, exemplified frequently in multidiscipli- tion.17,18 Prehabilitative intervention may be
nary care contexts.9–11 While multidisciplinary clinically indicated when the intended outcome
HNC clinics facilitate interprofessional com- is functional preservation in the setting of a
munication and coordination of care, these physiologically disruptive treatment, such as
clinics tend to be more common in tertiary with oropharyngeal radiotherapy (e.g., prophy-
care centers than in community or smaller lactic pharyngeal and masticator exercises).19,20
specialty healthcare institutions. Restoration-focused rehabilitation efforts may
Given the swallowing implications of HNC include a variety of physiologically based inter-
and its respective oncological treatments, a ventions designed to improve structural strength
speech–language pathologist (SLP) is a critical or range of motion (e.g., linguo-palatal compres-
member of the care team and should be involved sion, Shaker exercise, expiratory muscle strength
from the time of diagnosis or, at the very least, training [EMST]) and may include a variety of
before the initiation of treatment to maximize biofeedback tools (e.g., surface electromyogra-
functional outcomes.12,13 With respect to swal- phy, Iowa Oral Performance Instrument).21–24
 DECISION MAKING HEAD AND NECK/STARMER, EDWARDS 215

Table 1 Management Approaches to Head and Neck Cancer Dysphagia

Description Examples

Education- Education and counseling about functional Pre-laryngectomy counseling,

focused loss and/or changes from treatment or late radiation-associated dysphagia
disease with respect to deglutition
Prehabilitation- Functional preservation in the setting of Prophylactic swallowing exercises during
focused expected decline in function radiation therapy
Restoration- Restore/improve functional range of Shaker exercise and EMST for therapy
focused motion, strength, and coordination given targeting suprahyoid musculature and
impairment improving hyolaryngeal elevation
Compensatory- Augment typical swallowing patterns to Supraglottic swallowing for aspiration
focused improve pulmonary safety or improve after partial laryngectomy; respiratory-
efficiency swallow retraining for late-radiation
associated dysphagia
Surveillance- Routine swallowing imaging or clinical Annual instrumental swallowing
focused evaluation after acute treatment toxicities evaluation following radiation therapy for

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have subsided a tongue base tumor

Abbreviation: EMST, expiratory muscle strength training.

Compensation-based intervention (e.g., swallo- cacy. The SLP must have a thorough under-
wing strategies, respiratory-swallowing retrai- standing of their patient’s global functional
ning) may alternatively be indicated when status and demographic-based risks (e.g., using
there is limited prognosis of return to normal geriatric health screening tools) to not only allow
functioning, a clear immediate need to improve for a comprehensive assessment but also to
pulmonary safety or bolus flow parameters, or develop a patient-centered care plan.27,28 Risk
when there has been a limited response to stratification begins by understanding the
restoration-focused interventions, such as in disease-involved swallowing structures, the
the case of late radiation-associated dysphagia expected surgical plan, and baseline swallowing
(RAD).22,25 Finally, ongoing swallowing surveil- symptoms to determine whether a clinical
lance with imaging is essential for patients at risk assessment of swallowing risk or instrumental
for developing late effects from radiation therapy swallowing examination is indicated. In many
after acute toxicities have subsided, particularly cases, a presurgical instrumental baseline assess-
with oropharyngeal cancer patients—given func- ment will assist the treating medical/surgical
tional complications of trismus, soft-tissue fib- teams in making the most functionally aligned
rosis, and cranial nerve denervation which may treatment recommendations (e.g., assessing
not develop until years after treatment.26 In such function prior to consideration of organ-sparing
patients, early identification and intervention treatment for laryngeal cancer, or identifying
may change the outcome trajectory in high-risk silent aspiration in a patient who reports normal
patients (e.g., identifying and managing silent swallowing at baseline).29,30
aspiration before a pulmonary complication may There are numerous useful, evidence-based
develop). tools available when evaluating swallowing risk
and developing care goals, including patient-
and clinician-reported outcome measures (e.g.,
SLP MANAGEMENT OF THE the MD Anderson Dysphagia Inventory
SURGICAL HEAD AND NECK [MDADI] or the Functional Oral Intake Scale
CANCER PATIENT [FOIS]),31–33 standardized assessment tools
Management of the surgically treated patients (e.g., Mann Assessment of Swallowing Ability—
with HNC with dysphagia requires risk strati- Cancer [MASA-C] or the Modified Barium Swal-
fication and interventions that prioritize shared low Study Impairment Profile [MBSImP]),34,35 as
decision making, education, and patient advo- well as objective measure of lingual range of
216 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 40, NUMBER 3 2019

motion33 and maximal interincisal distance.36 to maintain dietary restrictions and multiple
Together with a thorough chart review and swallowing strategies.
patient interview, these tools will assist clinicians While patient preference is one factor that
in determining whether swallowing visualiza- may influence treatment, rehabilitation goals
tion is indicated and which instrumentation is may also be constrained by surgeon-mandated
favored (e.g., endoscopy vs. fluoroscopy).37,38 range of motion and functional use restrictions.
For many patients with HNC, instrumentation This may include limited PO or NPO orders,
is clearly favored (e.g., resections of the oropha- particularly in patients undergoing free flap
rynx, laryngopharynx, and hypopharynx). In reconstruction, though there is emerging evi-
others, such as patients with small tumors of dence supporting early reinitiation of PO
the anterior oral cavity (e.g., labial, buccal, and intake.43–45 In some cases, patients may
anterior one-third of oral tongue), instrumental undergo salvage resection and reconstruction
baseline assessment may not be as clinically after recurrence or organ failure following defi-
necessary due to less potential for baseline impact nitive nonsurgical treatments (e.g., functional
on pharyngeal swallowing safety and efficiency. laryngectomy with the goal of improved swal-
However, there are functional implications for lowing-related quality of life).46,47 Regardless

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swallowing safety and efficiency associated with as to the specifics of the surgery, the SLP plays a
oral cavity resections. Therefore, it remains primary role in guiding patients through the
important for the SLP to at least clinically assess process of realistic expectation setting related to
and educate the patient undergoing oral cavity functional changes, expected rehabilitation
resections prior to surgery. Surgical resections needs, and timelines while providing appro-
interrupting the floor-of-mouth or suprahyoid priate education and counseling to ensure ade-
musculature and those necessitating flap quate patient knowledge is gained.48
reconstruction come with increased risk of aspi- Postoperative rehabilitation may vary
ration and extended length of recovery, as oppo- depending on the aforementioned factors as
sed to a small, focal, oral resection with a primary well as the interval since surgery. Intervention
closure or locally advanced tissue flap.39–41 In goals in the acute postoperative period may
patients deemed high risk for pulmonary com- include training of strategic maneuvers to faci-
plications arising from aspiration (e.g., those litate bolus control or airway safety. Or, in more
with chronic obstructive pulmonary disease), complex cases, acute goals may simply be to
clinicians might also consider baseline pulmo- identify whether the patient can safely initiate
nary measures such as vital capacity, peak expi- some type of PO intake to minimize the
ratory pressure, and cough reflex testing.42 potential for disuse atrophy. Postacute goals
While humble, a simple peak flow meter and in the outpatient clinic often focus more on
disposable filters can be a meaningful addition to comprehensive goals related to restoration of
the dysphagia clinician’s toolset. maximal function whether it be with swallo-
Surgical patients should be active partici- wing-related range-of-motion and strengthe-
pants in setting goals and priorities for swallo- ning exercises or behavioral retraining of the
wing rehabilitation. Given that patients arrive airway-swallowing mechanisms to adapt to an
to these conversations with their own personal anatomical loss (e.g., partial laryngectomy).49,50
hopes and expectations for quality of life, the Additionally, there are times when it is apparent
SLP should be a partner, using his or her that additional evaluation and treatment needs
experiential, research, and theoretical know- are indicated and fall outside of the SLP’s scope
ledge to provide scaffolding for rehabilitation of practice. This may include situations such as
goals. At times, these perspectives may conflict; when nutritional inadequacy is suspected, ina-
however, it is the ethical duty of the SLP to dequate coping or resource utilization is suspec-
always respect patient autonomy. For example, ted, or when additional medical specialists are
some patients may find it acceptable to maintain needed to intervene in a patient’s dysphagia
adequate nutrition with a combination of (e.g., gastroenterology or laryngology). Given
enteral feeding and oral intake, while others the unique and evolving needs of the HNC
may find a feeding tube unacceptable and prefer patient, it is essential for SLPs to understand
 DECISION MAKING HEAD AND NECK/STARMER, EDWARDS 217

the roles of the various oncology team members aspiration of thin and mildly thick liquids
and the supporting allied health professionals (International Dysphagia Diet Standardisation
including registered dieticians, social workers, Initiative [IDDSI] Level 2). There was also
rehabilitation specialists, and additional patient moderate residue in the vallecula and on the
care providers.51 posterior pharyngeal wall for puree consistency
requiring liquid washes using a double swallow
in a modified supraglottic-swallow technique:
SURGICAL CASE STUDY (1) bolus placement in the oral cavity, (2) breath
A 49-year-old male with type-I diabetes, mild hold, (3) two successive swallows, and (4) cough
obstructive sleep apnea, hypertension, and for airway ejection. Mildly thickened liquids
hyperlipidemia was diagnosed with a T2 N1 and use of a compensatory swallowing maneu-
p16-postitive squamous cell carcinoma of the vers reduced painful coughing and aspiration.
right tonsil characterized as a firm, erythema- Given recommendations for supplemental PO
tous, and exophytic mass with clinical, CT-, intake with swallowing strategy recommenda-
and FNA-confirmed involvement of the ipsila- tions and consistencies of puree, mildly thi-
teral neck. Baseline patient- and clinician- ckened fluids, and a free water protocol, he

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reported swallowing outcome measures were discharged from the acute care unit with a
obtained and considered normal (i.e., MDADI nasogastric (NG) feeding tube.
score of 100 and FOIS score of 7). Upon exam, His feeding tube was removed by the sur-
his maximal interincisal opening was 55 mm geon 10 days postoperatively and a repeat FEES
and he demonstrated normal lingual, labial, in the outpatient clinic was conducted 24 hours
velar, and buccal sensorimotor function. An later to allow for a reduction in edema believed
endoscopic swallowing exam found functional to be related to the feeding tube. Upon presen-
pharyngeal swallowing physiology and laryngo- tation to the SLP clinic, he demonstrated mild
pharyngeal sensorimotor function. The patient cul-de-sac resonance and mild vocal roughness.
returned for presurgical counseling with SLP, Sensory impairment along the anterior bilateral
following a shared decision for frontline trans- tongue was stable with return of a functional
oral robotic surgery–assisted right partial oro- lingual range of motion in all directional planes.
pharyngectomy and ipsilateral neck dissection. Velar movement was mildly asymmetric with
He was evaluated clinically by an SLP 24 leftward deviation. Maximal interincisal open-
and 48 hours postoperatively. Evaluation revea- ing, initially 26 mm, increased to 30 mm after a
led reduced maximal interincisal opening, lin- set of active range-of-motion masticator exer-
gual edema, and reduced range of motion in all cises. FEES revealed complete velopharyngeal
directional planes with sensory loss along the closure, persistent supraglottic penetration of
anterior third of the bilateral oral tongue, secretions secondary to pyriform sinus pooling,
significant odynophagia, and frequent expecto- stable pharyngeal edema which continued to
ration and oral suctioning of secretions. Obser- obliterate the reservoir capacity of the bilateral
vational PO trials of various liquid consistencies pyriform sinuses, postcricoid hypertrophy, and
with postural compensations and swallowing persistent bilateral vocal process granulomas.
maneuvers resulted in persistent dysphagic PO trials of liquids and puree were adminis-
symptoms necessitating recommendation for tered given the patient’s reticence to attempt
instrumental evaluation. A bedside flexible solids secondary to fear and pain. There was
endoscopic evaluation of swallowing (FEES) mid-swallow penetration of all liquids and post-
performed 72 hours postoperatively found post- swallow aspiration of thin liquids from the
cricoid edema, bilateral vocal process granulo- pyriform sinuses and postcricoid spillover
mas, an expected surgical wound of the right through the posterior commissure. Supraglottic
oropharynx, and pharyngeal edema which obli- double swallows paired with a chin tuck with
terated the reservoir capacity of the bilateral right head rotation eliminated deep penetration
pyriform sinuses. There was deep glottic penet- and subsequent aspiration of liquids. Moderate
ration of secretions and postswallow pyriform liquid pyriform sinus residue and mild vallecu-
sinus spillover resulting in penetration and lar puree residue were reduced by employing
218 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 40, NUMBER 3 2019

multiple swallows and completing a liquid wash unplanned hospital care (admissions or visits to
with airway protection maneuvers. The patient the emergency department), dysphagia, and
agreed to a PO diet of puree and nectar liquids feeding tube use, particularly when concurrent
with a free water protocol with dietary modi- chemoradiation is applied.53,54 Patients in these
fications to reduce pulmonary risk, palliate high-risk groups should be more closely moni-
odynophagia, and reduce frequency of traum- tored during their treatment for complications
atic forces upon the vocal folds secondary to that may influence their intake. The SLP plays a
coughing (to allow the vocal process granulo- critical role on the care team in educating
mas to resolve). He was encouraged to return patients about these toxicities and strategies to
for a repeat FEES (
4 weeks post-op). The manage them.
examination revealed improved airway safety Chronic radiation-associated swallowing
and pharyngeal efficiency yielding recommen- toxicities are typically related to fibrosis. During
dations for a regular diet as comfort allows, radiation, there is an increase in reactive oxygen
unrestricted liquid intake, and follow-up pre- and nitrogen species, which lead to vascular and
paratory counseling, education, and prophylac- parenchymal cell death and tissue damage. The
tic exercise training given recommendations for body’s natural injury response mechanisms lead to

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adjuvant radiation therapy. hyperactivation of transforming growth factor-b
(TGF-b) and subsequent inflammation. Con-
nective tissue growth factor works in conjunction
SLP MANAGEMENT OF THE with TGF-b to induce sustained fibrosis. Fibrotic
NONSURGICAL HEAD AND NECK connective tissue then encases the nerves and
CANCER PATIENT muscles leading to reduced muscle mobility and
The majority of patients diagnosed with HNC subsequent atrophy. Fibrosis typically occurs
will require radiation as part of their cancer insidiously and progresses gradually in the weeks
treatment. This may be given following surgery or months following completion of radiation.
in an adjuvant setting or as the primary treatment Lymphedema may further contribute to dyspha-
modality, either with or without chemotherapy. gia as edematous structures such as the epiglottis
Acute toxicities during radiation such as painful and arytenoids may have limitations in regard to
mucositis, dysgeusia, and xerostomia may have a mobility and displacement.55 In a small subset of
negative impact on patient’s desire to eat and patients, late RAD may arise many years after
drink during treatment. As a result, appetite and completion of radiation. Late RAD is commonly
oral intake may suffer, placing the patient at associated with significant potential for cranial
higher risk for development of dysphagia due to neuropathies, reduced sensation, pulmonary
disuse atrophy. Following radiation, patients complications from chronic aspiration, and diffi-
have elevated risks of developing dysphagia, culty with maintenance of adequate nutrition.
which may be related to muscle weakness, Goals of care for patients undergoing radia-
soft-tissue fibrosis, chronic lymphedema, and/ tion-based treatment are very different than in
or cranial neuropathies. Speech pathologists many other populations of patients with dysp-
working with patients receiving radiation the- hagia. Although dysphagia intervention is
rapy should have a solid understanding of acute commonly reactive and restorative, dysphagia
and chronic changes related to radiation and how management in the radiation population is pri-
those may impact swallowing function. marily prevention based. Thus, the intention of
Acute toxicities of radiation may have a treatment is prehabilitation rather than rehabili-
marked impact on patient function during treat- tation. This prehabilitation begins with under-
ment. More severe levels of toxicity are anti- standing the patient’s baseline function and
cipated when patients receive concurrent expectations for function following treatment.
chemoradiation in contrast to induction chemo- In the head and neck population, subclinical
therapy followed by radiation or radiation dysphagia may be identified in approximately
alone.52 Additionally, patients over the age of 40% of patients prior to treatment. While in
70 years have been shown to have elevated rates many cases this pretreatment dysphagia is mild, in
of acute toxicity during treatment leading to patients with more advanced cancers or those
 DECISION MAKING HEAD AND NECK/STARMER, EDWARDS 219

with unrelated comorbidities, these baseline defi- mechanism in the first 1 to 2 years following
cits may influence both oncologic and therapeutic treatment, the primary goals will be rehabilita-
treatment decisions. Thus, we would advocate for tion and restoration of function to the greatest
pretreatment instrumental assessment of swallo- extent possible. For those patients who develop
wing function to better define baseline function late RAD, restoration of function may not be an
and to determine which patients may be at appropriate goal of care given poor efficacy of
elevated risk for development of dysphagia during rehabilitative exercises in this population. Skill-
radiation treatment. based interventions and compensations may be
Risk stratification is an important aspect of more appropriate in the late RAD setting.
care of the HNC population and should be Regardless of the specific goals of care the
based on knowledge of factors associated with SLP is addressing, education remains a corner-
dysphagia-related complications and thorough stone of SLP intervention across the different
understanding of an individual patient’s capa- subpopulations of radiation patients. Such edu-
bilities and functional reserve. Both videofluo- cation can serve to mitigate patient fear and
roscopy and endoscopic swallowing assessments anxiety, enhance adherence to treatment recom-
may be used effectively in the pretreatment mendations, and empower patients to be active

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setting to ascertain baseline function. Those participants in their health care. Initial education
patients with baseline dysphagia will be at prior to radiation will focus on education regar-
elevated risk for dysphagia-related complica- ding treatment toxicities, how to manage them,
tions during radiation including feeding tube and how they may contribute to long-term
dependence and admission for presumed aspi- swallowing issues if left unchecked. Specific
ration pneumonia. Such patients warrant close treatment-related toxicities that should be
follow-up with the SLP throughout their treat- addressed with patients prior to treatment due
ment course. The goals of care in this subgroup to their potential impact on oral intake include
will be to provide education regarding warning pain, dry mouth, and taste changes. For many
signs and symptoms of dysphagia, to monitor patients, during radiation their relationship with
for changes that may increase risk of complica- food may shift from a pleasurable experience to a
tions, to apply compensatory strategies and burdensome, unpleasant experience. It is impor-
modifications as needed, and to offer rehabili- tant for the SLP to acknowledge this at the early
tative care as appropriate. Patients presenting stage of treatment and to provide the patient with
without baseline changes to their swallowing information about why maintaining oral intake is
mechanism may need less direct clinician moni- critical from a nutritional and a long-term swal-
toring and compensatory adaptations. In this low function perspective.
population, a key goal of care is educating Pain in particular may have a dramatic
patients about the risks for future dysphagia. impact on patient adherence to oral intake and
Without understanding the importance of pre- prophylactic exercise protocols. Pain and fear of
vention, adherence to clinician recommenda- pain were cited as primary contributors to non-
tions may suffer. A major goal of care for all adherence in the Pharyngocise study.19 Radia-
patients receiving radiation is thorough educa- tion is known to produce both nociceptive and
tion regarding treatment toxicities that may neuropathic pain. Unfortunately, narcotic anal-
influence the patient’s ability to maintain oral gesics do not address the neuropathic aspect of
intake and complete prophylactic exercises, as pain. Thus, treatment teams need to consider
well as strategies to manage those side effects. alternative pain management strategies to add-
Goals of care will necessarily shift in the ress the neuropathic aspect of pain as well.
postradiation setting. In patients who have Gabapentin has been shown to successfully
recently completed radiation and have not minimize patient pain and narcotic use during
presented with significant dysphagia to date, radiation and has been associated with favorable
goals are focused on maintenance of function short- and long-term swallowing outcomes.56,57
and education regarding signs that are indica- The SLP can play an important role in educating
tive of worsening swallow function. In patients patients as to why it is important to prophylac-
who demonstrate changes to their swallowing tically start neuropathic pain medications.
220 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 40, NUMBER 3 2019

In addition to addressing pain, the SLP lactic PEG in patients receiving head and neck
should also provide education regarding the radiation. In selected populations, augmented
injury of the salivary glands during radiation, nutrition may be necessary. Risk stratification
which leads to significant changes in salivary may be challenging, but there is some limited
flow and consistency. The submandibular and evidence regarding which patients are at greatest
parotid glands are responsible for the produc- risk from a nutritional perspective. One retro-
tion of the majority of saliva. Because these spective review of patients with oropharyngeal
glands are relatively superficial, radiation often cancer undergoing chemoradiation found that
must penetrate through the glands to access the patients with body mass index (BMI) <25 at
target tumor. This results in a reduction in baseline, T stage of 3 or greater, or cumulative
watery saliva as early as the first 1 to 2 weeks of cisplatin dose of 200 mg/m2 had greater chance
treatment and an overall estimated prevalence of feeding tube placement during treatment.65
of xerostomia of 93% during radiation.58 Thus, Of those patients receiving a prophylactic tube in
SLPs will need to educate patients regarding another study, tube use was associated with male
strategies to minimize the impact of changes in gender, N stage >2, poor baseline performance
salivary flow to facilitate continued oral intake status, pretreatment dysphagia, and concurrent
chemotherapy.57 Thus, patients with several of

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and exercise performance. Such strategies may
include modification of the diet to include more the aforementioned risk factors may be consi-
soft, moist foods; use of pH balancing mouth dered higher risk for need of enteral feeding.
rinses; and avoidance of foods that may cause Reasonable alternatives to prophylactic PEG
increased mucosal irritation. Further exercises include use of a reactive PEG or NG tube.
may need to be performed with sips of fluid. Patients with reactive NG tubes tend to have
The aforementioned treatment toxicities tubes in place for shorter durations and have less
may have a negative impact on a patient’s desire potential for stricture formation.61,66 Severe late
and ability to maintain adequate nutrition and dysphagia rates may be double for patients
hydration. Thus, one of the critical decisions that receiving PEG rather than NG tube feedings.67
the SLP may play a role in making is whether or In cases where an NG tube may not be prefer-
not a patient requires supplemental nutrition/ able, reactive gastrostomy tubes have been
hydration via enteral tube feeding. The decision shown to provide comparable nutritional and
as to whether to proceed with feeding tube oncologic outcomes to prophylactic PEG with
placement is not an easy decision to make in more favorable functional outcomes.68,69 Thus,
most settings. This decision making is further decision making about the need for prophylactic
complicated by limited nonbiased research on or reactive tube feedings should take into consi-
this topic. Thus, the clinician needs to rely on deration patient-, tumor-, and treatment-related
principles of beneficence and nonmaleficence as factors. It should also be emphasized that the
well as the best quality evidence available and decision to place a feeding tube does not neces-
knowledge of the patient’s health status and sarily equate to the need for NPO status, and
functional reserve. Historically, feeding tubes patients with tubes should be encouraged to
were placed prophylactically for nutritional pur- continue swallowing at some level to minimize
poses; however, studies have demonstrated that future dysphagia risk.20,63 NPO status should be
weight loss rates were not necessarily favorable in avoided in this population whenever possible
patients undergoing prophylactic percutaneous due to the elevated risk of permanent dysphagia.
endoscopic gastrostomy (PEG).59,60 Further, Patients presenting with dysphagia after
recent research has demonstrated that patients radiation therapy pose a different set of clinical
with feeding tubes tend to swallow less by mouth issues and challenges. The duration of time
and are at increased risk for dysphagia and elapsed since treatment and the pattern of
stricture following treatment.61–63 Patients dysphagia over the first 2 years following treat-
undergoing prophylactic PEG in particular ment should be considered. Christianen and
have been shown to have higher rates of long- colleagues70 evaluated dysphagia patterns after
term PEG dependence.64 Thus, in the prophy- radiation therapy and stratified patients into five
lactic setting, there is a limited role for prophy- distinct categories (Table 2). While the proposed
 DECISION MAKING HEAD AND NECK/STARMER, EDWARDS 221

Table 2 Patterns of Postradiation Dysphagia70

Clinical characteristics Potential pathophysiology

Low persistent dysphagia No or minor dysphagia up to 2-y Xerostomia and direct radiation
follow-up damage to swallowing structures
Intermediate persistent Grade 1 dysphagia at 6 mo, relati- Xerostomia and direct radiation
dysphagia vely unchanged to 2-y follow-up damage to swallowing structures
Severe persistent Grade 2 or higher dysphagia at 6 Xerostomia and direct radiation
dysphagia mo, relatively unchanged to 2-y fol- damage to swallowing structures
low-up
Transient dysphagia Grade 2 or higher dysphagia at 6 mo Slow resolution of acute toxicities
that recovered by 2 y such as inflammation and reversible
edema
Progressive dysphagia Less than grade 2 dysphagia at 6 Progressive fibrosis
mo, progressing to at least grade 2
during 2-y follow-up

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pathophysiologies for these categories are not stricture, leading to silent aspiration, primarily of
proven, knowledge of the biological responses to pharyngeal residue. Unfortunately with late
radiation suggests these different categories RAD, traditional therapeutic exercises have
provide an appropriate framework for decision not shown significant benefit due to the severe
making regarding intervention strategies. and irreversible fibrosis.72 Similarly, neuromus-
Patients presenting with low, intermediate, cular electrical stimulation does not appear to
or severe persistent patterns of dysphagia will provide benefit for this population.73 It appears
likely benefit from direct interventions targe- that skill-based training (such as McNeill Dysp-
ting the dysphagia characteristics of concern. hagia Therapy Program74 and respiratory–swal-
This may mean addressing xerostomia, lym- low training75) and compensations76,77 are more
phedema, or reduced strength and mobility of appropriate interventions for patients with late
the muscles of deglutition. In practice, it would RAD. “Boot camp” approaches have been sug-
be challenging to differentiate between those gested for chronic and late RAD patients as well,
categories and patients with transient patterns with inclusion of intensive skill-based bolus-
of dysphagia. Thus, those patients with transi- driven interventions and airway protective inter-
ent dysphagia would most likely be treated in a ventions using EMST leading to encouraging
similar fashion to those patients with persistent early results.78,79
dysphagia, although the duration of treatment In addition to the decision-making chal-
may be abbreviated due to natural recovery. lenges inherent to rehabilitation interventions,
In contrast, however, patients presenting decisions regarding dietary restrictions and
with progressive dysphagia may require different recommendations may be difficult in patients
treatment strategies to slow or halt the progres- with postradiation dysphagia, particularly in
sion of fibrosis. Late-onset RAD would fall into patients with chronic or progressive dysphagia
this progressive category, although typically without nutritional or medical complications
would present at a later time point (>5 years related to their dysphagia. In contrast to dysp-
postradiation) when fibrosis and cranial neuro- hagia stemming from other etiologies, many
pathies have advanced. In contrast to other patients with HNC often have a greater degree
phenotypes of dysphagia related to radiation, of functional reserve and less potential for the
Awan et al71 defined late RAD as “delayed onset risk factors that have been previously associated
or progression of pharyngeal dysphagia preceded with aspiration pneumonia.80 In a patient who
by a long interval of adequate functional recovery is maintaining weight and avoiding pulmonary
from the acute toxicities of radiotherapy.” The complications, NPO status and PEG place-
hallmark characteristics of late RAD include ment should not be the immediate response to
severely inefficient swallowing, not related to an ineffective swallow. Rather, the clinician
222 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 40, NUMBER 3 2019

should engage in shared decision making with the evidence of potential for subclinical dyspha-
the patient. This should include evidence-based gia, his radiation oncologist referred him for a
information regarding pneumonia risk as well formal swallowing evaluation and preradiation
as strategies that may minimize pneumonia risk intervention. A FEES examination revealed mild
such as compensatory postures/strategies, pharyngeal residue but no laryngeal penetration
immaculate oral hygiene, and maintaining an or aspiration. The patient was on an unrestricted
active lifestyle. Even in patients who have diet with stable weight and a BMI of 30. The
experienced medical complications from their SLP recommended the patient not to receive a
dysphagia, there should be a comprehensive prophylactic feeding tube given that he did not
discussion regarding future risks and patient exhibit significant risk factors for needing a tube.
goals of care, so that patients may make a The patient was provided with prophylactic
decision that supports their personal goals. It swallowing exercises, which he completed incon-
is important to remember that the majority of sistently throughout the treatment. He required
patients with HNC are neurotypical and extensive counseling by the SLP to maintain oral
capable of making informed decisions regarding intake due to loss of appetite due to taste changes.
their care. In situations where it is decided to Though he lost some weight during treatment,

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pursue oral intake despite aspiration, the clini- this was less than 5% of his ideal body weight;
cian should carefully document the education therefore, the SLP, dietician, and oncology team
provided and patient/care team conclusions. concurred that a feeding tube was not necessary
Finally, the clinician working with patients for his nutrition. His posttreatment videofluo-
with HNC receiving radiation treatment may roscopic swallowing assessment revealed mild
need to make decisions regarding referrals to pharyngeal dysphagia related to reduced pharyn-
other providers. Stricture is a common problem geal propulsion from restricted pharyngeal const-
in patients who have received head and neck riction and tongue base retraction. Epiglottic tilt
radiation with estimated incidence of 10 to was diminished, but no laryngeal penetration or
20%.81–83 Thus, referral to a gastroenterologist aspiration was noted. His Dynamic Imaging
or otolaryngologist may be appropriate for stric- Grade of Swallowing Toxicity (DIGEST) sco-
ture management. As previously mentioned, res84 were as follows: safety ¼ 0, efficiency ¼ 1,
lymphedema can impact swallowing function. overall severity grade ¼ 1. He was encouraged to
Lymphedema management may be provided by continue his maintenance exercises and to return
appropriately trained SLPs, occupational thera- to a normal diet as tolerated.
pists, and physical therapists. When edema One year following radiation, his swallow
appears to be inhibiting ROM of the swallowing was minimally impaired and marked only by
musculature, referral for treatment should be mild reduction in pharyngeal constriction and
pursued. Patients will often encounter issues sluggish epiglottic tilt without penetration or
with nutrition as a result of their treatment aspiration. Six years after completion of radia-
and/or dysphagia. The SLP may be an important tion, the patient contacted his radiation oncolo-
advocate for ensuring appropriate follow-up gist with complaints of increased difficulty
with a registered dietician. swallowing and speaking. Despite his perceived
difficulty, his weight was stable and he had not
experienced pneumonias. He was referred for a
NONSURGICAL CASE STUDY videofluoroscopic swallowing study. Oral motor
The following case study exemplifies some of the evaluation revealed right hemi-tongue atrophy
challenges that may be encountered when wor- with fasciculations. His swallow study revealed
king with nonsurgical HNC patients. JL was a moderate-severe deficits with severely reduced
56-year-old male diagnosed with a HPV-asso- pharyngeal propulsion with retention of appro-
ciated squamous cell carcinoma of the right ximately 50% of each bolus after the swallow. He
tongue base (T2N2b). His treatment team had persistent deep penetration to the vocal folds
recommended primary chemoradiation. At the with liquids after the swallow due to overflow of
time of diagnosis, he was not aware of any residue but no aspiration. His DIGEST scores
changes in his swallowing. Despite this, given were as follows: safety grade ¼ 2, efficiency
 DECISION MAKING HEAD AND NECK/STARMER, EDWARDS 223

grade ¼ 3, overall severity grade ¼ 3. There larynx is dysfunctional at baseline), what diet
was no evidence of stricture to account for the level is safe and appropriate, whether tube fee-
noted residue. ding is necessary, how to maintain and restore
The SLP had a candid conversation with the function, and when to focus rehabilitative efforts
patient regarding the nature of the dysphagia and on compensation. Risk-guided decision making
the prognosis for late RAD. They identified is critical in this population, as many patients are
compensatory strategies such as a head tilt to at a lower risk for complications from dysphagia
the left and multiple effortful swallows which due to fewer medical comorbidities and neuro-
minimized the residue and therefore the penet- typical baseline status. Thus, SLPs providing
ration. Because the patient was maintaining his care to this population should have a compre-
weight and avoiding pulmonary complications, a hensive understanding of the different phenoty-
feeding tube was not recommended; however, pes of dysphagia in HNC, factors associated with
the patient was counseled that progression of the elevated risk of developing complications, and
dysphagia could lead to adverse consequences. patient goals of care. At all stages of decision
The patient was enrolled in a course of therapy making, patient autonomy and preference should
focusing primarily on respiratory swallowing be emphasized. When thoughtful decision

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coordination therapy and EMST use to mini- making is applied in the management of dysp-
mize aspiration risk and complications. Respira- hagia associated with HNC, patient function and
tory swallowing coordination therapy utilized outcomes may be optimized.
biofeedback pairing submental EMG and nasal
airflow to allow the patient to visualize where in DISCLOSURES
the respiratory cycle he was swallowing and thus Neither author has any financial or nonfinancial
improved his ability to adjust his abnormal disclosures.
respiratory-swallowing pattern. Oral care was
emphasized to minimize the risk of aspiration
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