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

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Otolaryngology – Head and Neck Surgery 168(4)

Table 4. Prevention of Dysphagia Among HNC Patients: Statements That Reached Consensus Number Statement

Mean Outliers

15 Nutritional evaluation and management by an RDN contribute to improved nutritional outcomes of HNC patients. 7.36 0 24 HNC patients have improved swallowing outcomes if encouraged to continue eating and drinking, guided by a dysphagia specialist, throughout cancer treatment. 8.09 0 29 Radiation-associated dysphagia can be reduced by contouring and avoiding swallowing organs at risk during head and neck radiotherapy. 8.27 0 31 A multidisciplinary team with members from head and neck surgery, radiation oncology, medical oncology, speech-language pathology, nutrition, and nursing is preferred to provide comprehensive care for HNC patients and minimize dysphagia associated with treatment. 8.45 0 32 Prophylactic swallowing exercises bene fi t HNC patients undergoing radiation therapy by optimizing functional status and quality of life. 7.09 1 33 Acute and chronic pain management in HNC patients contributes to improved swallowing and nutritional outcomes. 7.70 1 34 The use of IMRT is associated with less xerostomia than conventional techniques, which has a positive impact on swallowing function. 7.55 0 35 HNC patients treated with IMRT have improved swallowing outcomes in comparison to those individuals treated with less conformal techniques. 8.09 1 36 Dysphagia-optimized IMRT improves patient-reported swallowing outcomes vs standard IMRT. 7.27 0 37 The addition of chemotherapy to HNC treatment regimens is associated with worse swallowing outcomes in HNC patients. 7.45 0 39 Cricopharyngeal myotomy improves swallowing outcomes in patients undergoing laryngectomy. 7.36 1

Abbreviations: HNC, head and neck cancer; IMRT, intensity-modulated radiation therapy; RDN, registered dietitian nutritionists.

management. Statements not reaching consensus by the development group included the optimal use of enteral nutrition or reactive feeding tubes. Also, statements concerning the effect of acupuncture and chronic lymphedema on swallowing function were not supported by group consensus. Surveillance for Dysphagia Among HNC Patients Six statements relating to the surveillance of dysphagia in HNC patients were developed and all reached a consensus (Table 6). These statements highlighted optimal strategies for ongoing monitoring and detection of dysphagia in HNC patients throughout the lifespan. These included lifelong assessment by an MDT, individualized dysphagia care, and evaluation of new ‐ onset dysphagia in HNC survivors. Both dysphagia ‐ related patient ‐ reported out comes and measures of health are used for surveillance and inform the frequency of assessment. Discussion Risk Factors for Dysphagia Among HNC Patients Several patient ‐ related factors increase the risk of dys phagia in HNC patients (Table 1; Statement 1) including advanced age (greater than 62 years), pretreatment swallowing dysfunction, weight loss, performance status, and smoking and/or alcohol abuse. 1,15 ‐ 18 Tumor ‐ related

factors associated with poorer swallowing outcomes include advanced tumor stage (T3 ‐ T4) and nodal stage. 16,19 Hypopharyngeal 17,20,21 and oropharyngeal subsites are also associated with worse long ‐ term swallowing out comes. 19,22 ‐ 24 Moreover, treatment ‐ related factors play a signi fi cant role in posttreatment dysphagia. Surgical de tails, including tracheostomy, tumor resection extent, surgical approach, and types of reconstruction alter the anatomy and function of the swallowing organs contri buting to dysphagia. 1 The use of adjuvant radiation is also associated with dysphagia and has side effects in both acute and late settings. 1,20 Factors associated with prolonged feeding tube dependence include the dose of radiation to the larynx (supraglottic and glottic), pharyngeal constrictor muscles, the contralateral parotid gland, and the bilateral neck as well as the volume of the area treated. 16,17,24,25 In addition, concomitant treatment with chemotherapy sig ni fi cantly worsens swallowing outcomes due to the increased prevalence of oral mucositis among other factors. Other associated treatment factors impacting dysphagia severity include total radiation dose, fractionation regimen, target volumes, and treatment delivery techniques. 1,15 Multimodality therapies such as “ triple therapy ” which includes surgery, radiation, and chemotherapy portents a greater risk for swallowing dysfunction. 17 Patients who undergo TORS + CRT have demonstrated poorer long ‐ term swallowing outcomes than those who receive surgery or organ ‐ preservation therapy alone. 26