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

585

Kuhn et al.

dysarthria, coughing on the swallow, and change in voice quality after swallowing. 169,172 Retrospective assessment of such MDTs has shown excellent patient adherence, a good collection of clinician/patient outcome tools during treatment, and favorable nutrition and quality of life outcomes. 69,173 Randomized controlled trials are in progress to evaluate the functional and nutrition out comes of multidisciplinary nutritional rehabilitation for HNC patients, which will help to standardize nutritional assessment and allocation of resources to this patient population. 174 The development group reached a consensus that obtaining patient ‐ reported dysphagia ‐ related out comes are an important component of ongoing HNC care (Table 6; Statement 58). 175,176 Patient ‐ reported outcome measures (PROMs) have been developed to quantify patients' subjective experience with swal lowing dif fi culty. Some PROMs like the Eating Assessment Tool ‐ 10 have been developed to measure dysphagia in the general population. 177 Other PROMs like the MDADI and Swallowing After Total Laryngectomy questionnaire were speci fi cally devel oped for HNC survivors. 178,179 PROMs can help identify patients with negative consequences of swal lowing dysfunction such as malnutrition or aspiration risk, 180,181 and therefore complement conventional clinical evaluation. A sudden or rapid deterioration in PROM scores may be a sign of disease progression or recurrence and ought to trigger an appropriate workup. 182 The change in PROMs values between pre ‐ and posttreatment has been shown to be prognostic for overall survival among HNC patients and thus particular attention should be paid to patients with persistently depressed scores. 151,183,184 The NCCN guidelines for follow ‐ up with respect to speech and swallowing do not provide a speci fi c cadence or method for screening for dysphagia. There was strong consensus that the speci fi c cadence and screening for dysphagia in HNC survivors must be dictated by the individualized patient, tumor, and treatment factors (Table 6; Statement 59). The development group agreed that dysphagia surveillance in HNC patients includes measures of health such as nutritional status, weight, and lung function (Table 6; Statement 60). The NCCN guidelines recommend that patients with ongoing dys function have regular visits with an SLP until the patient establishes a stable baseline following the completion of HNC treatment. The expert group agreed that new ‐ onset dysphagia necessitates a workup to exclude recurrence or new primary tumors in HNC survivors who are otherwise presumed to be disease ‐ free (Table 6; Statement 17). A study on patient ‐ reported pretreatment swallowing measures found that HNC patients who reported pretreatment dysphagia were at greater risk of recurrence and death from the disease. 185 Any wor sening or new symptoms of dysphagia after HNC

treatment should prompt close evaluation for recur rence or new primary.

Conclusions A development group of otolaryngologists, SLPs, a medical oncologist, a radiation oncologist, a head and neck nurse, and an RDN developed consensus statements on dysphagia management among HNC patients based on available evidence and expert opinion, utilizing an established protocol. Numerous topics related to dys phagia among HNC patients were identi fi ed in which there were signi fi cant variations in practice and contro versy, including risk factors, screening, evaluation, pre vention, interventions, and surveillance. Statements were generated to improve the quality of care provided to HNC patients. The group members highlighted the importance of early identi fi cation of HNC patients at high risk of dysphagia based on clinical characteristics or screening outcomes. The involvement of an MDT is preferred to optimize comprehensive dysphagia care in HNC patients. Evaluations by SLP and RDN before, during, and after HNC treatment guide diet recommen dations and informs patients suitable for prophylactic and therapeutic interventions. Dysphagia surveillance among HNC patients is lifelong and is facilitated by MDT and PROMs. Further research is needed with a focus on functional outcomes of HNC care pathways and pro spective randomized trials comparing swallowing inter ventions to better guide and individualize the care of dysphagia among HNC patients. Acknowledgments The authors gratefully acknowledge the support of Elizabeth Moreton for conducting the literature search and Joe Reyes for his administrative support. Author Contributions Maggie A. Kuhn , writer, chair; M. Boyd Gillespie , writer, assistant chair; Stacey L. Ishman , writer, methodologist; LisaE. Ishii , writer, methodologist; Rebecca Brody , writer; EzraCohen , writer; Shumon I. Dhar , writer; Kate Hutcheson , writer; Gina Jefferson , writer; Felicia Johnson , writer; Anais Rameau , writer; David Sher , writer, Heather Starmer , writer; Madeleine Strohl , writer; Karen Ulmer , writer; Vilija Vaitaitis , writer; Sultana Begum , writer, AAO ‐ HNSF staff liaison; Misheelt Batjargal , writer, AAO ‐ HNSF staff liaison; Nui Dhepyasuwan , writer, AAO ‐ HNSF staff liaison. Disclosures Competing interests : Stacey L. Ishman, MD, MPH: clinical trial (Inspire Medical), NIH funding; Ezra Cohen, MD, FRCPSC, FASCO: consulting fee: Bayer, BioNTech, Eisai, Gilead, Merck, MSD and Regeneron; Kate Hutcheson, PhD: personal fees — Medbridge Inc, ATOS Medical and American Speech Language and Hearing Association; research funding: NIH, Thrive