xRead - Swallowing Disorders in the Adult Patient (October 2024)
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Otolaryngology – Head and Neck Surgery 168(4)
patients. In the largest study, cohorts were compared before and after the initiation of a proactive swallow therapy program, the authors found reduced use of feeding tubes and increased oral intake following proactive swallow therapy. 68 The totality of the data would suggest that MDTs which include SLP improve swallowing outcomes and patient satisfaction, even if the overall effects are numerically modest. Swallowing pre habilitation may minimize the progression of dysphagia from HNC treatment by maintaining muscle mass, strength, range of motion, and coordination. Swallow exercise programs speci fi cally target the oral cavity, pharynx, and larynx. 69 A variety of potential prehabilita tion schemes have shown improved functional swallowing including the patient's ability to handle a greater variety of food and drink, maintain muscle mass, reduce trismus, improve taste, smell, and salivary function, and decrease the need for feeding tubes. 12,70 ‐ 72 Whereas others report no signi fi cant difference in swallow outcomes and feeding tube use. 69 However, there is a lack of consensus on exercises prescribed, repetitions per exercise, repetitions per day, timing to initiate prehabilitation, and duration of prehabilitation therapy. Dysphagia prehabilitation likely most bene fi ts a speci fi c subset of HNC patients. Future multicenter randomized clinical trials are needed to fully de fi ne speci fi c exercise programs targeting a particular HNC patient group and the timing and intensity of therapy needed to achieve lasting results. A key to prophylactic swallowing intervention is maintaining muscular engagement and mobility of the swallowing system during radiation. There is some discrepancy in the literature regarding the value of prophylactic swallowing therapy during radiation therapy. 73,74 Though studies have varied in their intervention approach with regard to exercises chosen and dose of exercise, 75 most have demonstrated improvements in multiple domains in cluding quality of life, 76 diet level, 71 physiologic func tion, 12,77 maintenance of muscle mass, 78 and feeding tube dependence. 79 Many studies that fail to demonstrate the bene fi t of prophylactic exercises suffer challenges with poor adherence and feasibility rather than poor ef fi cacyof the intervention or methodologic barriers. On this basis, the development group agreed that prophylactic swal lowing exercises bene fi t HNC patients undergoing radia tion therapy by optimizing functional status and quality of life ( Table4 ; Statement 32). Given the issues regarding adherence, the MDT must ensure that the treatment proposed is feasible and that barriers to adherence are addressed in a proactive manner. Clinical models also need to be considered given early evidence that clinician ‐ directed therapy appears to be more ef fi cacious than home ‐ based patient ‐ directed therapy. 80 Maintaining oral intake during HNC treatment is one strategy to limit long ‐ term dysphagia risk. Langmore et al demonstrated that continued oral intake through the end of HNC treatment were associated with more favorable diet levels 1 ‐ year posttreatment. 81 Furthermore,
they found that even in those patients who had a feeding tube during treatment, continuing some level of oral intake yielded better swallowing outcomes than patients who were nil per os (NPO). 82 Continuing oral intake during radiation therapy may be challenging for many patients due to anticipated treatment toxicities. It is critical for the dysphagia specialist to work closely with the MDT to ensure optimal management of treatment toxicities to support a patient's ability to continue per os intake. For example, the Eat All Through Radiation Therapy program was developed to provide a framework for clinician ‐ supported oral intake targeting swallowing preservation. 83 Consistent with this literature, the devel opment group agreed that HNC patients have improved swallowing outcomes if encouraged to continue eating and drinking, guided by a dysphagia specialist, throughout cancer treatment ( Table 4 ; Statement 24). Medical nutrition therapy (MNT) incorporating nutrition evaluation and ongoing management, im plemented by an RDN throughout HNC treatment, is a cost ‐ effective, low ‐ risk intervention that can improve patient nutrition outcomes (Table 4; Statement 15). 31 ‐ 34 MNT aims to maintain or lessen reductions in nutritional status, decrease symptom burden, and minimize the development of malnutrition. Several studies speci fi cally evaluate patients receiving radia tion therapy to the head, neck, or gastrointestinal regions and have shown that individualized nutrition interventions and counseling improve nutrition out comes, including calorie and protein intake, 84,85 reduce deterioration in nutritional status, weight, and fat ‐ free mass loss, and enhance symptom toler ance, 86 and physical function. 85,87 Furthermore, patient ‐ centered outcomes, including global quality of life markers declined less and recovered more quickly in those receiving RDN ‐ directed nutrition interventions. 63,85,88 The vast majority of HNC patients experience pain prior to, during, or following treatment, regardless of treatment modality. 89 The development group agreed that the management of pain is critical to engage in oral intake and preventing swallowing deterioration (Table 4; Statement 33). In a randomized controlled trial of prophylactic swallowing therapy, pain and fear of pain were cited as primary contributors to nonadherence. 78 There was consensus that acute and chronic pain management in HNC patients contributes to improved swallowing and nutritional outcomes. Considering pain management in this population, it is important to factor in the potential for both nociceptive and neuropathic pain. Neuropathic pain is particularly prevalent in patients undergoing head and neck radiation 90 and is generally not responsive to narcotic analgesics. 91 As an example, the prophylactic use of gabapentin has been associated with lower pain ratings during HNC treat ment, 92 reduced use of feeding tube during treatment, 93 improved short ‐ term diet outcomes and swallowing
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