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

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Kuhn et al.

continuum of HNC care, instrumental swallow evaluation is optimal to visualize the safety and ef fi ciency of bolus clearance through the aerodigestive tract while simulta neously examining swallow physiology. Regardless of the manner of screening or risk strati fi cation, there was strong consensus that in HNC patients who fail dysphagia screening, instrumental swallow evaluation provides in sight into the nature of swallowing impairment (Table 3; Statement 10). The utility of instrumental swallow evaluation in the HNC population is long recognized due to a high prevalence of sensory impairment (ie, “ silent ” aspiration), altered anatomy (eg, edema, recon struction), and physiologic impairment in HNC patients with dysphagia obligating visualization of the aerodiges tive tract during swallowing. Psychometrically sound clinician ‐ graded ratings of instrumental examinations may further enhance the clinical yield of these proce dures. 41 ‐ 45 There was strong consensus that instrumental evalua tion procedures (FEES or VFSS) are useful swallowing evaluation methods for HNC patients after radiotherapy (Table 3; Statement 11). Common physiologic impair ments include incomplete pharyngeal constriction, tongue base retraction, hyolaryngeal excursion, epiglottic inver sion, and pharyngoesophageal opening 46 ‐ 48 that can occur alongside structural changes such as stricture and submucosal edema of the laryngopharynx. Sensory impairments are also common. Aspiration is often “ silent ” in this population, particularly in long ‐ term HNC survivors with profound laryngeal sensory depriva tion reported in subpopulations with late radiation ‐ associated dysphagia. 49 The choice of “ best ” instrumental evaluation is matched to the clinical context as both FEES and VFSS offer relative advantages. 50,51 Therewas strong consensus that FEES affords direct visualization of the swallowing mechanism at the point of care in HNC patients, whereas VFSS provides functional imaging of the oral cavity and upper esophagus in HNC patients (Table 3; Statements 18 and 19). HNC patients with tracheostomy represent a unique population who requires speci fi c attention. Tracheostomy alters aerodigestive tract physiology and subglottic pressure generation with implications on swallow safety and ef fi ciency. 52 Furthermore, factors that necessitate tracheostomy in HNC also contribute to oropharyngeal dysphagia. As such, there was strong consensus to perform swallowing evaluation prior to oral diet initiation in HNC patients with tracheostomy (Table 3; Statement 20). There is substantial debate regarding both screening and evaluation of oropharyngeal swallowing after tra cheostomy. A systematic review of 6 published reports of the modi fi ed Evan's Blue Dye Test in patients with and without HNC reported inadequate diagnostic accuracy with highly variable sensitivity to detect aspiration between 38% and 95% and relatively better speci fi city between 79% and 100%. 53 In absence of best practice screening data in this population, as an initial step, there

was strong consensus that bedside swallow assessment by an SLP is useful to evaluate swallowing safety following tracheostomy (Table 3: Statement 9). Another unique population of HNC patients is those undergoing total laryngectomy (TL) which permanently separates the airway from the digestive tract with inherent implications on swallowing function. The postsurgical leak is a common barrier to re ‐ initiation of oral intake, with an incidence reported between 10% to 28% depending on prior radiation therapy and closure technique. 54 The optimal method of evaluation and ideal timing to initiate oral intake after TL is debated, with published studies largely supporting radiographic assess ment in the form of a VFSS with barium or water ‐ soluble iodinated contrast prior to initiation. 55 ‐ 58 VFSS also allows for simultaneous evaluation for other common sources of dysphagia in this population (eg, velophar yngeal insuf fi ciency, stricture, or pseudodiverticulum). 59 As such, there was strong consensus for VFSS following TL to evaluate for a postsurgical leak ( Table 3 ; Statement 21). Appreciating the common co ‐ occurrence of malnutri tion and dysphagia, there was strong consensus for nutrition evaluation by an RDN and the use of validated nutrition assessment tools to identify malnutrition and other nutrition problems as part of a comprehensive nutrition assessment for HNC patients ( Table 3 ; Statement 8). 36 The PG ‐ SGA 60 and Subjective Global Assessment tools 61 generate valid and reliable data when completed by adult patients with cancer in acute and ambulatory care settings. 62,63 Studies with HNC patients have used the PG ‐ SGA to identify malnutrition and direct nutrition interventions. 63 ‐ 65 Evaluation of additional assessment parameters can address common cancer ‐ related nutrition issues. Body composition assessment with dual X ‐ ray absorptiometry, computed tomography (CT) scans, or bioimpedance analysis can offer insight into the presence of sarcopenia, often masked by over weight or obese weight status and fl uid accumulation. 29 Sarcopenic dysphagia, de fi ned as total body sarcopenia that includes the swallowing muscles, makes identifying muscle wasting critically important in HNC patients. 66,67 Routine nutrition reassessments will identify ongoing changes in nutritional status. Dysphagia Prevention Among HNC Patients There was strong consensus for the preference of an MDT to curtail the impact of dysphagia among HNC patients (Table 4; Statement 31). An MDT includes expert HNC team members, including those who maintain awareness of dysphagia as a potential complication of HNC and its treatment. Studies have examined the impact of an MDT on swallowing using historical comparisons or cross ‐ sectional designs. 68 These trials demonstrated improved swallowing function by integrating speech and swallow therapy programs into the multidisciplinary care of