xRead - Swallowing Disorders in the Adult Patient (October 2024)

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Otolaryngology – Head and Neck Surgery 168(4)

access to timely and evidence ‐ based swallowing evaluation, management, and education for HNC patients and their families. 11,12 Reasons for disparities in dysphagia care among HNC patients include the predominant focus on cancer treatment with reduced emphasis on the management of cancer ‐ related complications, lack of appropriate resources or expertise, and con fl icting evidence supporting which inter ventions are most likely to improve dysphagia ‐ related outcomes. As a result, there is substantial practice variation in the management of HNC ‐ related dysphagia, with many patients referred for dysphagia evaluation months to years after HNC treatment, if they are ever referred at all. 12 Given discrepancies in care and substantial knowledge gaps, the management of dysphagia in HNC patients was selected as a topic for expert consensus statement (ECS) development by the American Academy of Otolaryngology ‐ Head and Neck Surgery Foundation (AAO ‐ HNSF) Guidelines Task Force (GTF). The objective of this ECS is to formulate areas of consensus among a group of experts in the fi eld to identify potential methods to reduce the burden of dysphagia in HNC patients from the time of diagnosis and throughout the lifespan. The primary aim was to highlight areas of controversy and identify opportunities to improve the recognition and rehabilitation of swallowing impairment, as well as to reduce the severity and duration of dysphagia and its impact on the quality of life in the HNC population. Methods This ECS was developed according to an a priori protocol 13 (previously used by AAO ‐ HNS to successfully develop other consensus statements) with the following steps: (1) de fi ne the subject of the ECS as management of dysphagia in HNC patients, (2) recruit the expert development group, (3) vet potential con fl icts of interest among proposed development group members, (4) per form a systematic literature review, (5) determine the scope and population of interest for the ECS, (6) develop topic questions and consensus for statements for each topic question, (7) develop and implement modi fi ed Delphi method surveys, (8) revise the ECS in an iterative fashion based on survey results, and (9) aggregate the data for analysis and presentation. The pertinent details of each of these steps will be brie fl y described. The topic of “ Prevention and Management of Dysphagia in Head & Neck Cancer Patients ” was proposed for an ECS by the AAO ‐ HNS Airway and Swallowing Committee. After deliberation, the AAO ‐ HNSF GTF approved and prioritized the suggestion; development group leadership was selected; and administrative support was allocated. Development group membership was strategically established to ensure appropriate representation of all relevant stakeholder groups and organizations within otolaryngology, head and neck ECS Topic Clari fi cation, Scope Re fi nement, and Development Group Recruitment

Keywords dysphagia, head and neck cancer, laryngeal cancer, nasophar yngeal cancer, oral cavity cancer, oropharyngeal cancer, radiation, swallowing

Received September 8, 2022; accepted February 1, 2023.

S wallowing is a life ‐ sustaining function that is critical for hydration, nutrition, management of secretions, and consumption of required medications. Swallowing function also contributes to the quality of life through the enjoyment of food and beverage, the social interaction of mealtime, and the shared cultural experience of the cuisine. Safe and ef fi cient swallowing is the result of a series of complex and well ‐ coordinated voluntary and involuntary musculoskeletal actions which are intricately regulated via mucosal sensory receptors, cranial nerves, brainstem centers, and higher cortical controls. Disruption of one or multiple of these components may result in the development of swallowing symptoms, or dysphagia. Dysphagia at diagnosis is common in head and neck cancer (HNC) patients due to tumor involvement of upper aerodigestive tissues important for normal swal lowing. Dysphagia is reported at presentation in up to 28% of all HNC patients, and in up to 50% of patients with pharyngeal cancers. 1 Dysphagia is also an acute and chronic side effect of HNC treatment due to the traumatizing effects of surgery, radiation, and che motherapy on the tissues of the upper aerodigestive tract. Therefore, dysphagia prevalence typically increases from disease presentation through treatment to long ‐ term posttreatment surveillance, ultimately affecting up to 45% to 75% of HNC survivors. 2,3 With the global incidence of HNC increasing by 36% over the past decade, partly driven by increasing numbers of human papillomavirus ‐ associated oropharyngeal cancers in younger patients, the prevalence of survivors with 4 HNC ‐ related dysphagia is likewise expected to increase into the foreseeable future. 5 HNC patients with dysphagia are at risk of complica tions including medication noncompliance, malnutrition, dehydration, pneumonia, and death. 6,7 Aspiration pneu monia has been observed in 24% of HNC patients treated with chemoradiotherapy over a 5 ‐ year period. 8 Outcomes from aspiration among HNC patients are poor with reports of approximately one ‐ third of those hospitalized dying within 30 days of admission. 8 Additionally, HNC patients with dysphagia have signi fi cantly reduced quality of life and higher rates of anxiety and depression as well as decisional regret 9 about their cancer treatment compared to those without dysphagia. 10 Despite increasing awareness that modern organ ‐ preservation treatment protocols do not necessarily translate into function preservation, there continues to be limited