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

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Otolaryngology – Head and Neck Surgery 168(4)

therapy contributes to improved swallowing in HNC patients with lymphedema (Table 5; Statement 52). Components of lymphedema management include patient education as to the chronic nature of the disease and complete decongestive therapy including manual lym phatic drainage, compression, exercises and stretching, and skin care. 147 Surgical Interventions The development group reached a consensus for the use of pharyngoesophageal dilation in HNC survivors who report dysphagia and have identi fi ed stenosis (Table 5; Statement 53). Radiotherapy causes tissue ischemia with fi brosis which may result in luminal stenosis in 5.7% to 16.7% of irradiated HNC patients. 151 Dilation of stenotic segments may be safely performed using a variety of dilators (bougies, balloon dilators, olive ‐ tip dilators) with multiple anesthesia options (general anesthesia, sedation, or local anesthesia for interventions in the of fi ce). 152 There is a theoretical advantage to balloon dilators, which apply controlled radial forces on the stenosed segment, compared to bougies which apply shearing forces, 153,154 however safety and ef fi cacy outcomes of the T2 techni ques are similar in benign strictures based on randomized controlled trials. 155 ‐ 159 Combined anterograde and retro grade dilation or rendezvous procedure may be offered in cases of near ‐ complete or complete stenosis. 160 The overall success in improving dysphagia with dilation in HNC patients has been reported to range between 42% and 100%. 115 Esophageal perforation is the most com monly reported complication, with an estimated rate per patient at 5.4%. 161 There was strong consensus supporting the use of select surgical interventions to address aspiration and improve pulmonary health in HNC patients with laryngeal dysfunction and aspiration or signi fi cant risk of aspiration ( Table 5 ; Statement 54). For example, a tracheotomy may be performed to improve pulmonary clearance that results from substantial, chronic aspiration. 162 Also, vocal fold medialization, either by injection augmentation or laryngeal frame work surgery, has been shown to be safe and improve voice and swallowing outcomes in those with glottic insuf fi ciency. 163,164 However, long ‐ term prevention of aspiration has not yet been demonstrated after medialization in HNC patients. Glottic and supra glottic closure procedures preserving the laryngeal framework have been proposed but wound dehiscence, voice limitations, and dependence on tracheostomy have prevented the widespread adoption of these techniques. 160 Laryngotracheal separation and tra cheoesophageal diversion are reversible procedures shown to be effective in preventing aspiration, how ever postoperative fi stulas, poor voice outcomes, and persistent feeding tube dependency are drawbacks to these strategies. 165

The development group agreed on the selective use of functional TL for intractable aspiration in HNC patients with concurrent tracheostomy and nonfunctional voice who continue to aspirate despite NPO status ( Table 5 ; Statement 55). Elective TL was historically used for the dysfunctional larynx, 166 with support provided by a retrospective study in 2012 from MD Anderson which demonstrated functional TL after previous treatment for HNC decreased the incidence of pneumonia, decreased dependence on enteral nutrition, and allowed some level of oral intake. 167 Fifteen of the 23 patients had successful voice restoration with tracheoesophageal puncture. Topf et al found elective TL to be an effective intervention in preventing aspiration and restoring oral diet, with acceptable complication rates. Conversely, other aspects of quality of life may be affected by TL. In 11 patients undergoing TL for dysfunctional larynx at The Netherlands Cancer Institute, the biggest areas of concern were speech dif fi culty, smell and taste changes, mouth opening, and saliva thickness. 168 Roughly half of the patients reported an improvement in swallowing and dyspnea with the other half reporting a deterioration of their swallowing and dyspnea complaints as compared to before surgery. Although aspiration is prevented with the elective TL, most patients will still have dysphagia postoperatively. Of note, a majority of patients with elective TL have been reported to require pharyngoeso phageal segment dilation to improve swallowing func tion. 116 Therefore, patients and their treatment team must consider the risks of experiencing the negative conse quences of aspiration against the alterations in voice and swallowing that come with the various surgical options. Dysphagia Surveillance Among HNC Patients Swallowing dysfunction is the most common ongoing quality ‐ of ‐ life complaint experienced by up to 55% of HNC patients treated with multimodality therapy. 5,169,170 Therefore, the development group agreed that lifelong monitoring for the signs and symptoms of dysphagia is important for HNC survivors (Table 6; Statement 57). Furthermore, strong consensus supported improved nutrition outcomes and health status when HNC patients followed by an MDT (Table 6; Statement 56). 171 HNC survivor quality of life concerns are regularly addressed by comprehensive history and physical exam ination. Symptoms and signs of dysphagia include coughing, throat clearing during meals, dif fi culty chewing, nasopharyngeal regurgitation during eating, prolonged meal duration, dietary limitations/avoidances, history of pneumonia, weight loss, and aspiration. However, patients may not report any of these due to altered laryngopharyngeal sensations. Physical examina tion should assess for trismus, mucosal dryness, tongue mobility and strength, cranial nerve function, state of dentition, and oral hygiene. The clinician, aided by both FEES and VFSS, should also evaluate for voice quality,