xRead - Swallowing Disorders in the Adult Patient (October 2024)
10976817, 2023, 4, Downloaded from https://aao-hnsfjournals.onlinelibrary.wiley.com/doi/10.1002/ohn.302, Wiley Online Library on [08/07/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
581
Kuhn et al.
function, 48 and excellent 1 ‐ year posttreatment swallowing outcomes. 94 Bene fi ts have also been noted when gaba pentin has been used in the postoperative setting. 95 The advent of IMRT over the past 2 decades has remarkably improved swallowing outcomes without sacri fi cing oncologic results. There was strong con sensus that IMRT techniques are the preferred standard for reducing xerostomia which may impact swallowing outcomes (Table 4; Statements 34). In the seminal PARSPORT randomized study, Nutting et al showed a clear, statistically signi fi cant reduction in the patient ‐ reported dry mouth at every time point from 3 to 24 months, with the signi fi cantly more measured salivary fl ow in the contralateral parotid in the IMRT cohort. A smaller randomized study of IMRT versus conventional radiotherapy in nasopharynx cancer showed an over twofold reduction in observer ‐ rated xerostomia, 96 and importantly, there was signi fi cantly less long ‐ term feeding tube use in the IMRT cohort. 97 A third randomized trial of IMRT versus three ‐ dimensional ‐ conformal radiotherapy (ie, using CT ‐ based planning but conventional fi elds) in non ‐ nasopharyngeal HNC con fi rmed physician ‐ reported xerostomia improvements lasted through 10 years of follow ‐ up. As in the previous randomized studies, there was an apparent improvement in oral intake as well, as there was signi fi cantly less chronic weight loss in the IMRT cohort. 98 On the basis of this evidence, there was a strong consensus that IMRT confers decreased xerostomia and impacts the preservation of swallowing ability (Table 4; Statement 33). Likewise, the development group reached an agree ment that IMRT parotid ‐ sparing techniques cause lower rates of dysphagia compared to conventional radio therapy (Table 4; Statement 35). Retrospective studies consistently found that patients treated with IMRT experienced superior swallowing outcomes than those individuals treated with conventional radiation therapy measured by physician ‐ reported toxicity grade, 99 physician ‐ reported functional score, 100 or patient ‐ reported outcome. 101 The Italian Head and Neck Radiotherapy Study Group summarized these data, highlighting the multiple domains of superiority in swallowing outcomes seen with IMRT. 102 Additionally, there was consensus supporting second ‐ generation IMRT techniques that go beyond parotid sparing to preserve swallowing organs at risk (Table 4; Statements 29 and 36). Several landmark dosimetry studies showed that the dose to swallowing structures, including the pharyngeal constrictors, 103 ‐ 106 larynx, 105,107 fl oor of mouth, 108,109 and esophageal inlet, 110 ‐ 112 signi fi cantly in fl uenced dysphagia outcomes. This work culmi nated in a phase III randomized trial in which patients with pharyngeal cancer were treated with either standard IMRT or dysphagia ‐ optimized IMRT, which signi fi cantly reduced the dose to the pharyngeal musculature (ie, the superior/middle/inferior constrictors). 113 Patients treated
on the experimental arm, experienced a statistically signi fi cant improvement in MD Anderson Dysphagia Inventory (MDADI) score 1 year after treatment, thus establishing dysphagia ‐ avoidance IMRT as the standard ‐ of ‐ care planning approach. 114 Assessment of the contribution of chemotherapy to dysphagia is complex due to many factors including the timing of chemotherapy (induction, concurrent, adju vant), dose, speci fi c agents, swallowing evaluation meth odology, and use of other treatment modalities (surgery and radiotherapy). Most prospective, randomized studies that established the utility of chemotherapy in locally advanced HNC were performed prior to the adaptation of validated swallowing outcome measures. Therefore, data to adequately conclude that chemotherapy is associated with a difference in swallowing outcome is lacking. The development group agreed that the enhanced toxicity associated with chemotherapy during concurrent therapy with radiation or as a component of trimodal therapy following surgery is associated with an increased risk of acute and chronic dysphagia (Table 4; Statement 37). There was consensus that concurrent cricopharyngeal myotomy at the time of TL reduces dysphagia following the surgery (Table 4; Statement 39). In normal swal lowing, the cricopharyngeus muscle relaxes, thus allowing a bolus to pass distally into the esophagus. However, in many HNC patients, including those undergoing TL, the cricopharyngeus muscle fails to completely relax, which in addition to inef fi cient bolus transit, can lead to poor alaryngeal voice outcomes. 115,116 Cricopharyngeal myotomy has been shown to be bene fi cial in reducing cricopharyngeal muscle spasms and improving tracheoe sophageal speech in patients with tracheoesophageal voice prostheses. 117 Patients that have not undergone cricopharyngeal myotomy during TL require may require additional adjuvant therapy such as dilation, botulinum toxin injection, or secondary myotomy. 118 ‐ 120 Dysphagia Interventions in HNC Patients Interventions for dysphagia among HNC patients was the topic area yielding the most statements from the development group owing to signi fi cant clinical practice variability, lack of abundant high ‐ quality evidence, and its importance as an opportunity for care optimization. Statements pertaining to intervention that reached con sensus included ones relating to swallowing therapy, feeding tubes, diet allocation, patient and caregiver education or counseling, oral care, lymphedema therapy, and surgery. Swallowing Therapy Dysphagia management in the HNC population is primarily prevention ‐ based, so there was a strong consensus that swallowing therapy is most effective when initiated early in HNC treatment (Table 5; Statement 40). When comparing patients treated
Made with FlippingBook Ebook Creator