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

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578

Otolaryngology – Head and Neck Surgery 168(4)

Table 7. Statements That Were Classi fi ed as No Consensus Number Statement

Group Mean Outliers

3

Symptom-driven dysphagia evaluation in HNC patients (such as for dehydration, malnutrition, coughing, or choking) is useful to establish impairments to the swallowing mechanism. Patient-reported questionnaires are good screening tools for dysphagia in head and neck patients. Comprehensive screening for dysphagia in HNC patients includes clinician-reported outcome measures. The Patient-Generated Subjective Global Assessment identi fi es nutrition risks in HNC patients. HNC patient and caregiver education on the signs and symptoms of swallowing impairment helps preserve swallowing function. Placement of prophylactic feeding tubes in HNC patients may improve 6-month quality of life. Feeding through prophylactic feeding tubes extends long-term dependence on enteral feeding in HNC patients. Chemotherapy options for curative HNC treatment do not differ in their propensity to impact swallowing function. Enteral nutrition is bene fi cial when an HNC patient is unable to eat for >7 d or has anticipated inadequate intake (<60%) for >10 d. Reactive use of a feeding tube is appropriate in HNC patients with uncontrolled aspiration or inability to adequately meet nutritional needs by mouth. Acupuncture mitigates early toxicities of HNC chemoradiation therapy such as pain, xerostomia, dysgeusia, and dysphagia. Chronic lymphedema from HNC treatment is associated with enduring fi brosis of swallowing related structures.

Screening 6.64

1

4

Screening 6.36

2

5

Screening 6.45

2

6

Screening 5.45 Prevention 5.36

2 1

22

27 28

Prevention 4.73 Prevention 6.09

3 1

38

Prevention 4

1

45

Interventions 7.73

2

46

Interventions 8.09

2

50

Intervention 5.45

0

51

Interventions 6.82

1

Abbreviation: HNC, head and neck cancer.

pretreatment patient perception of swallowing dysfunc tion in comparison to instrumental assessment by VFSS or clinician assessment, 27 the development group agreed on the bene fi t of newly diagnosed HNC patients undergoing pretreatment dysphagia assessment by a clinician including instrumental assessment (Table 2; Statement 2). At a minimum, the pretreatment evalua tion serves as a reference for posttreatment evaluation and management of dysphagia. There is no standardized screening assessment tool for pre ‐ HNC treatment evaluation. The total dysphagia risk score (TDRS) is one validated strati fi cation tool that predicts the development of dysphagia due to curative radiotherapy. TDRS incorporates T ‐ classi fi cation, neck irradiation, weight loss, primary tumor site, and type of radio therapy planned (ie, concurrent chemoradiotherapy, accelerated radiotherapy). 28 In addition to dysphagia, HNC patients are at high risk for malnutrition. 29 While the cause of malnutrition is typically multifactorial, dysphagia is a frequent contri butor 30 and can profoundly impact the patient during treatment and recovery. Nutrition screening to identify the risk of malnutrition is an integral part of the initial evaluation for HNC patients. 29 Early identi fi cation of nutrition risk can lead to timely and appropriate interventions, thus improving patient outcomes. 31 ‐ 34 A brief, easy ‐ to ‐ use screening tool, such as the malnutrition screening tool, 35 facilitates nutrition risk identi fi cation 29 (Table 2; Statement 7). RDNs or other trained healthcare

personnel can implement screening tools to identify patients at risk for a more thorough evaluation. Routine rescreening is critical to assess for changes in nutrition status based on the clinical setting. 36 An objective scoring system coupled with patient self ‐ assessment, such as the Patient ‐ Generated Subjective Global Assessment (PG ‐ SGA), 37 may appropriately identify those patients in need of nutrition intervention from an RDN, dysphagia prehabilitation, and even those who would bene fi t from a feeding tube prior to HNC treatment initiation. Evaluation of Dysphagia in HNC Patients Proactive swallowing referral to an SLP is a best practice standard recommended by the National Comprehensive Cancer Network (NCCN) among HNC patients experi encing dysphagia or for those whose treatment is likely to affect swallowing. 38 This practice standard derives from a body of evidence supporting the utility of pretreatment swallowing evaluation to detect not only moderate to severe dysphagia or aspiration, 39 but even mild dysphagia that is shown to increase the severity and prevalence of dysphagia after treatment. 40 There was strong consensus that pretreatment instrumental swallowing evaluation establishes baseline swallowing function and impairment in HNC patients who report symptoms of dysphagia or who are at risk of developing dysphagia during treatment (Table 3; Statement 13). As is the case across the