Effects of radiotherapy with or without chemotherapy on tongue strength and swallowing in patients with oral cancer

Effects of exercise on swallowing and tongue strength in patients with oral and oropharyngeal cancer treated with primary radiotherapy with or without chemotherapy

Tongue strength is reduced in patients treated with chemoradiotherapy for oral/oropharyngeal cancer. Tongue strengthening protocols have resulted in improved lingual strength and swallowing in healthy individuals, as well as in patients following a neurological event. However, no studies have examined the efficacy of tongue strengthening exercises on tongue strength, swallowing, and quality of life (QOL; Head and Neck Cancer Inventory) in patients treated with chemoradiotherapy. A randomized clinical trial examined the effects of a tongue strengthening programme paired with traditional exercises vs. traditional exercises alone. Dependent variables included tongue strength, swallowing, and QOL in a group of patients with oral and oropharyngeal cancer treated with primary radiotherapy with or without chemotherapy. Differences with regard to tongue strength and oropharyngeal swallow efficiency (OPSE) were not observed within or between groups. QOL in the eating and speech domains improved following treatment in both groups. However, the experimental group demonstrated greater impairment in QOL in the social disruption domain following treatment, whereas the control group demonstrated a slight improvement in functioning. Tongue strengthening did not yield a statistically significant improvement in either tongue strength or swallowing measures in this patient cohort. Patient compliance and treatment timing may be factors underlying these outcomes.

Nonsurgical treatment: swallowing rehabilitation

This article provides an overview of nonsurgical and nonpharmacologic treatments for oropharyngeal dysphagia. The speech-language pathologist (SLP) is the primary member of the swallowing management team who will provide this type of dysphagia management. The primary focus of the SLP for dysphagia management is first to eliminate or reduce aspiration risk, as well as to improve or restore swallowing function. Ultimately, the management plan will depend on the physiologic underpinnings of the disorder and patient variables such as cognition, motivation, and ability to attend therapy sessions or participate in therapy.

Tongue Strength as a Predictor of Functional Outcomes and Quality of Life after Tongue Cancer Surgery

Objectives:

Surgical resection of oral cancer can result in altered speech, swallowing, and quality of life (QOL). To date, the oral outcome variables of tongue strength, tongue and jaw range of motion, and saliva production have not been extensively assessed. This pilot study was done to assess tongue strength along with other oral outcomes and their relationship to performance status for speech, swallowing, and QOL after partial glossectomy. Our aim was to create a norm for what should be considered a normal tongue strength value in this population. We hypothesized that patients with tongue strength of 30 kPa or greater would perform better on the performance status scale and various QOL measures than do patients with tongue strength of less than 30 kPa.

Methods:

We used a cross-sectional design in this study. The postoperative assessment included 1) Performance Status Scale and Karnofsky Performance Status Scale; 2) oral outcome variables of tongue strength, jaw range of motion, and saliva production; and 3) patient-rated QOL ratings via Eating Assessment Tool, M. D. Anderson Dysphagia Inventory, EORTC-H&N35, and Speech Handicap Index.

Results:

Patients with tongue strength of at least 30 kPa performed better on the performance status scales and various QOL measures. The cutoff score of 30 kPa for tongue strength measures revealed a trend in predicting performance on the scales and QOL measures.

Conclusions:

The oral outcome variables correlated with performance status for speech, swallowing, and QOL. We propose a norm for tongue strength in this population, based on the trend seen in this group of patients, as none previously existed. Future studies are under way that incorporate a larger sample size to further validate this norm. Future studies will also examine oral functional outcome measures in a larger population by including other oral and oropharyngeal sites to help predict speech and swallow performance status and QOL.

Development and preliminary validation of a patient-reported outcome measure for swallowing after total laryngectomy (SOAL questionnaire)

OBJECTIVES

To develop and validate a laryngectomee-specific questionnaire to investigate swallowing function. This paper describes the generation of questionnaire items, pretesting with laryngectomees and a preliminary validation.

DESIGN

This study employed 2 phases: questionnaire development and questionnaire validation. Items were developed from patient (n = 10) and clinician (n = 6) focus groups. Content checking, acceptability and face validity were determined through pretesting with 10 laryngectomees and via consensus feedback from 35 speech and language therapists. During preliminary validation, the 17-item final questionnaire was administered to 3 different groups. Discrimination amongst groups was established by comparing questionnaire responses of a laryngectomee group (n = 19) with known dysphagic (n = 19) and non-dysphagic groups (n = 20). Questionnaire responses from the reference dysphagic group were compared with an instrumental assessment of swallowing, the modified barium swallow (MBS).

SETTING

Large urban teaching hospital.

PARTICIPANTS

Speech and language therapists, laryngectomees, non-dysphagic volunteers, post-radiotherapy dysphagic patients.

MAIN OUTCOME MEASURE

Preliminary validation of SOAL questionnaire.

RESULTS

Normal, laryngectomee and dysphagic groups had significantly different SOAL scores, as did laryngectomees with different degrees of swallowing impairment (Kruskall Wallis, P << 0.001). The subjective SOAL score had a strong positive correlation with the reference measure of ratings on the MBS (r = 0.5; P = 0.03).

CONCLUSIONS

The swallowing outcome after laryngectomy (SOAL) questionnaire is a simple, self-administered tool to assess swallowing function post-total laryngectomy. Further specific testing with a laryngectomy cohort is necessary for full validation. Its potential value lies in screening for dysphagia in clinics or during long-term follow-up of laryngectomees.

One-way valved speech bulb obturator using a tracheoesophageal prosthesis

This article describes the fabrication procedures to create a one-way valved speech bulb obturator.

Swallowing dysfunction in head and neck cancer patients treated by radiotherapy: review and recommendations of the supportive task group of the Italian Association of Radiation Oncology

PURPOSE

Dysphagia is a debilitating complication in head and neck cancer patients (HNCPs) that may cause a high mortality rate for aspiration pneumonia. The aims of this paper were to summarize the normal swallowing mechanism focusing on its anatomo-physiology, to review the relevant literature in order to identify the main causes of dysphagia in HNCPs and to develop recommendations to be adopted for radiation oncology patients. The chemotherapy and surgery considerations on this topic were reported in recommendations only when they were supposed to increase the adverse effects of radiotherapy on dysphagia.

MATERIALS AND METHODS

The review of literature was focused on studies reporting dysphagia as a pre-treatment evaluation and as cancer and cancer therapy related side-effects, respectively. Relevant literature through the primary literature search and by articles identified in references was considered. The members of the group discussed the results and elaborated recommendations according to the Oxford CRBM levels of evidence and recommendations. The recommendations were revised by external Radiation Oncology, Ear Nose and Throat (ENT), Medical Oncology and Speech Language Pathology (SLP) experts.

RESULTS

Recommendations on pre-treatment assessment and on patients submitted to radiotherapy were given. The effects of concurrent therapies (i.e. surgery or chemotherapy) were taken into account.

CONCLUSIONS

In HNCPs treatment, disease control has to be considered in tandem with functional impact on swallowing function. SLPs should be included in a multidisciplinary approach to head and neck cancer.

Swallowing, nutrition and patient-rated functional outcomes at 6 months following two non-surgical treatments for T1-T3 oropharyngeal cancer

PURPOSE

Altered fractionation radiotherapy with concomitant boost (AFRT-CB) may be considered an alternative treatment for patients not appropriate for chemoradiation (CRT). As functional outcomes following AFRT-CB have been minimally reported, this exploratory paper describes the outcomes of patients managed with AFRT-CB or CRT at 6 months post-treatment.

METHODS

Using a cross-sectional analysis design, functional outcomes of 14 AFRT-CB and 17 CRT patients with T1-T3 oropharyngeal cancers were explored at 6 months post-treatment. Clinical and instrumental swallow assessments, weight and nutritional status, and the functional impact of treatment were examined.

RESULTS

Inferior outcomes were observed for the CRT patients on the RBHOMS (p = 0.03) which was reflected in diet and fluid restrictions with 18% of the CRT group requiring modified fluids and diets. Although a trend (p = 0.07) was noted for increased lingual deficits and aspiration risk for fluids in the CRT group, no other significant differences were observed. Both groups experienced an average of 10 kg weight loss and reported reduced general and swallowing-related function.

CONCLUSIONS

These preliminary data suggest functional outcomes following AFRT-CB and CRT were largely comparable at 6 months post-treatment. Treatment intensification in any form may contribute to impaired function which requires multidimensional intervention. Larger cohort investigations with systematic methodology are needed to further examine these initial findings.

Swallowing function following postchemoradiotherapy neck dissection: review of findings and analysis of contributing factors

OBJECTIVE

This study assesses swallowing function following chemoradiotherapy and neck dissection in head and neck cancer patients and investigates clinical, treatment, and neck dissection factors associated with dysphagia.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary care center.

SUBJECTS AND METHODS

Eighty-eight patients undergoing neck dissection after chemoradiotherapy for advanced head and neck cancer were reviewed. Dysphagia outcome measures included weight loss, diet, gastrostomy tube (GT) dependency,and video swallow findings of aspiration or stenosis. In addition,the researchers created a Diet/GT Scale, with scores ranging from 1 to 5. Univariate and multivariate analysis of clinical, treatment, or neck dissection factors potentially associated with dysphagia outcome measures was undertaken.

RESULTS

Peak mean weight loss was 17% at 6 months after chemoradiotherapy. At 12 months, a soft/regular diet was taken by 78 of 88 patients (89%), and only 1 of 88 patients (1%)was nil per os. Gastrostomy tube dependence at 6, 12, and 24 months was 53%, 25%, and 10%, respectively. The Diet/GT score was 5 (gastrostomy tube removed and soft/regular diet)for 47% at 6 months, 74% at 12 months, and 89% at 24 months.Multivariate analyses revealed that higher tumor stage was associated with a lower Diet/GT score at 12 months (P = .02)and gastrostomy dependence at 12 months (P = .01) and 24 months (P = .04).

CONCLUSION

Despite the addition of neck dissection to chemoradiotherapy,nearly all patients took a soft or regular diet and reached a Diet/GT score of 5, and only 1% remained nil per os. A higher tumor stage is associated with a lower Diet/GT score and gastrostomy tube dependency beyond 12 months.

A prospective investigation of swallowing, nutrition, and patient-rated functional impact following altered fractionation radiotherapy with concomitant boost for oropharyngeal cancer

Altered fractionation radiotherapy for head and neck cancer has been associated with improved locoregional control, overall survival, and heightened toxicity compared with conventional treatment. Swallowing, nutrition, and patient-perceived function for altered fractionation radiotherapy with concomitant boost (AFRT-CB) for T1-T3 oropharyngeal squamous cell carcinoma (SCC) have not been previously reported. Fourteen consecutive patients treated with AFRT-CB for oropharyngeal SCC were recruited from November 2006 to August 2009 in a tertiary hospital in Brisbane, Australia. Swallowing, nutrition, and patient-perceived functional impact assessments were conducted pretreatment, at 4-6 weeks post-treatment, and at 6 months post-treatment. Deterioration from pretreatment to 4-6 weeks post-treatment in swallowing, nutrition, and functional impact was evident, likely due to the heightened toxicity associated with AFRT-CB. There was significant improvement at 6 months post-treatment in functional swallowing, nutritional status, patient-perceived swallowing, and overall function, consistent with recovery from acute toxicity. However, weight and patient perception of physical function and side effects remained significantly worse than pretreatment scores. The ongoing deficits related to weight and patient-perceived outcomes at 6 months revealed that this treatment has a long-term impact on function possibly related to the chronic effects of AFRT-CB.

A randomized preventive rehabilitation trial in advanced head and neck cancer patients treated with chemoradiotherapy: feasibility, compliance, and short-term effects

The aim of this study was to assess the effect of (preventive) rehabilitation on swallowing and mouth opening after concomitant chemoradiotherapy (CCRT). Forty-nine patients with advanced oral cavity, oropharynx, hypopharynx and larynx, or nasopharynx cancer treated with CCRT were randomized into a standard (S) or an experimental (E) preventive rehabilitation arm. Structured multidimensional assessment (i.e., videofluoroscopy, mouth-opening measurement, structured questionnaires) was performed before and 10 weeks after CCRT. In both S and E arms, feasibility was good (all patients could execute the exercises within a week) and compliance was satisfactory (mean days practiced per week was 4). Nevertheless, mouth opening, oral intake, and weight decreased significantly. Compared to similar CCRT studies at our institute, however, fewer patients were still tube-dependent after CCRT. Furthermore, some functional outcomes seemed less affected than those of studies in the literature that did not incorporate rehabilitation exercises. Patients in the E arm practiced significantly fewer days in total and per week, but they obtained results comparable to the S arm patients. Preventive rehabilitation (regardless of the approach, i.e., experimental or standard) in head and neck cancer patients, despite advanced stage and burdensome treatment, is feasible, and compared with historical controls, it seems helpful in reducing the extent and/or severity of various functional short-term effects of CCRT.

Respiratory-swallow phase patterns and their relationship to swallowing impairment in patients treated for oropharyngeal cancer

BACKGROUND

Unstable respiratory-swallowing coordination has been associated with disorders and disease. The goals of this study were (1) to describe respiratory-swallow patterns in patients with dysphagia consequent to treatments for cancers of the oropharynx and (2) to determine the association between respiratory-swallow patterns, airway invasion, and overall severity of swallowing impairment.

METHODS

This prospective, cross-sectional design compared respiratory-swallow patterns in 20 patients treated for oropharyngeal cancer and 20 healthy, age-matched control participants. Nasal airflow direction was synchronously recorded with videofluoroscopic imaging in participants who swallowed 5-mL thin liquid barium boluses.

RESULTS

Respiratory-swallow patterns differed between groups. Most control participants initiated and completed swallowing bracketed by expiratory airflow. Swallowing in patients often interrupted inspiratory flow and was associated with penetration or aspiration of the bolus.

CONCLUSIONS

We suggest nonexpiratory bracketed respiratory-swallowing phase patterns in patients with oropharyngeal cancer may place patients at greater risk of airway penetration or aspiration during swallowing.

Management of patients treated with chemoradiotherapy for head and neck cancer without prophylactic feeding tubes: the University of Pittsburgh experience

OBJECTIVES/HYPOTHESIS

Mucositis and dysphagia are common complications of chemoradiotherapy (CRT) for head and neck cancer that may necessitate nutritional support with a gastrostomy tube (G-tube).

METHODS

We reviewed records of patients who underwent and completed CRT, which included at least one traditional chemotherapeutic, for previously untreated head and neck cancer. G-tubes were placed as needed. The timing and duration of G-tube placement and treatment-related complications and risk factors for long-term G-tube use were analyzed.

RESULTS

A total of 91 consecutive patients who received CRT, 68 as primary and 23 as postoperative treatment, were studied. Radiation doses ranged from 59.4 to 74 Gy (median, 70 Gy). Seventy-nine percent of patients received platinum-based therapy during CRT. Severe mucositis occurred in 40% of patients. Forty percent of patients required G-tube placement (15 prior to CRT and 21 during CRT). Median duration of G-tube use was 5.8 months. Two patients who had a G-tube placed during CRT developed a G-tube-related complication. At 6 and 12 months, 15 (18%) and four (6%) patients who were disease free were using G-tubes, respectively. Patients with G-tubes placed prior to CRT or advanced T stage had longer G-tube dependence.

CONCLUSIONS

With aggressive supportive care it is feasible to avoid G-tubes in the majority of patients undergoing CRT for head and neck cancer. G-tube placement prior to CRT due to pre-existing dysphagia and advanced T stage are associated with prolonged G-tube dependence.

Effect of gamma irradiation on ultimate tensile strength of enamel and dentin

The effect of gamma irradiation therapy on the ultimate tensile strength (UTS) of enamel and dentin in relation to prism orientation, dentin tubule orientation, and location is unknown. It was hypothesized that tubule and prism orientation, location, and irradiation have an effect on the UTS of dental structures. Forty human third molars were used, half of which were subjected to 60 Gy of gamma irradiation, in daily increments of 2 Gy. The specimens were evaluated by microtensile testing. Results showed that irradiation treatment significantly decreased the UTS of coronal and radicular dentin and of enamel, regardless of tubule or prism orientation. With or without irradiation, enamel was significantly stronger when tested parallel to its prismatic orientation. Coronal and radicular dentin of non-irradiated specimens presented significantly higher UTS when tested perpendicularly to tubule orientation. However, when the teeth were irradiated, the influence of tubule orientation disappeared, demonstrating that irradiation is more harmful to organic components.

Effects of chemoradiotherapy on voice and swallowing

PURPOSE OF REVIEW

Chemotherapy has been found to result in comparable survival rates to surgery for head and neck cancer. However, toxicity can often be worse after chemoradiotherapy, with impairment in voice, swallowing, nutrition, and quality of life. Investigators are attempting to modify radiotherapy treatment regimens to spare organs that have an impact on swallowing. This review will highlight voice and swallowing impairment seen after chemoradiotherapy, as well as treatment for voice and swallowing disorders in this population. Results of newer radiotherapy regimens will also be highlighted.

RECENT FINDINGS

Specific oropharyngeal swallowing motility disorders after chemoradiotherapy have been identified. Damage to specific structures has been correlated with specific pharyngeal phase swallow impairment. Swallowing function and quality of life have been examined over time, with improvement seen in both. Preventive/prophylactic swallow exercise programs have been encouraging. Chemoradiotherapy effects on voice have been identified in terms of acoustic, aerodynamic, and patient and clinician-rated perception of function. Improvement in voice has also been observed over time after chemoradiotherapy. Voice therapy has been found to have a positive impact on voice and perceptual measures in this population.

SUMMARY

Current studies show some improvement in swallow function after swallow and voice therapy in patients treated with chemoradiotherapy. Further, there is a suggestion of improved swallow function with sparing of organs with specific radiotherapy protocols. Future research needs to focus on specific voice and swallow treatment regimens in the head and neck cancer patient treated with chemoradiotherapy, specifically, timing, frequency, duration, and specific treatment types.

Effects of Chemoradiotherapy on Tongue Function in Patients With Head and Neck Cancer

In this review article, the effects of radiotherapy ± chemotherapy on tissues and on oropharyngeal swallowing are reviewed. In addition, normal tongue function for swallowing is reviewed, as are the effects of tongue exercise programs designed to improve tongue strength and swallow functioning. Current literature on swallow exercise programs for head and neck cancer patients is provided. Also discussed are potential new avenues for research in this population.

Treatment of oral and pharyngeal dysphagia

Research on treatment of oropharyngeal dysphagia has supported several treatment approaches. Treatment can include postural changes, heightening preswallow sensory input, voluntary swallow maneuvers, and exercises. Evidence to support the efficacy of these procedures is variable. An instrumental study of a patient's oropharyngeal swallow forms the basis for treatment selection.

The videofluorographic swallowing study

This article describes the evidence for the physiologic foundation and interpretation of the videofluorographic swallowing study (VFSS). The purpose and clinical efficacy of VFSS are explained. Standardization of the VFSS procedure, protocol, interpretation, and reporting is highlighted as a critical step in future clinical practice and research. Individualized evidenced-based rehabilitation strategies are presented as key components that are systematically applied during the VFSS procedure and integrated into the swallowing management plan. A new tool that has been developed and tested for the quantification of swallowing impairment is introduced.

Rehabilitation of dysphagia following head and neck cancer

Patients who have cancers of the oral cavity, pharynx, or larynx may be treated with surgery, radiotherapy, chemotherapy, or a combination of these modalities. Each treatment type may have a negative impact on posttreatment swallowing function; these effects are presented in this article. A number of rehabilitative procedures are available to the clinician to reduce or eliminate swallowing disorders in patients treated for cancer of the head and neck. The various procedures-including postures, maneuvers, modifications to bolus volume and viscosity, range-of-motion exercises, and strengthening exercises-and their efficacy in patients treated for head and neck cancer are discussed.

MBS measurement tool for swallow impairment--MBSImp: establishing a standard

The aim of this study was to test reliability, content, construct, and external validity of a new modified barium swallowing study (MBSS) tool (MBSImp) that is used to quantify swallowing impairment. Multiple regression, confirmatory factor, and correlation analyses were used to analyze 300 in- and outpatients with heterogeneous medical and surgical diagnoses who were sequentially referred for MBS exams at a university medical center and private tertiary care community hospital. Main outcome measures were the MBSImp and index scores of aspiration, health status, and quality of life. Inter- and intrarater concordance were 80% or greater for blinded scoring of MBSSs. Regression analysis revealed contributions of eight of nine swallow types to impressions of overall swallowing impairment (p < or = 0.05). Factor analysis revealed 13 significant components (loadings >/= 0.5) that formed two impairment groupings (oral and pharyngeal). Significant correlations were found between Oral and Pharyngeal Impairment scores and Penetration-Aspiration Scale scores, and indexes of intake status, nutrition, health status, and quality of life. The MBSImp demonstrated clinical practicality, favorable inter- and intrarater reliability following standardized training, content, and external validity. This study reflects potential for establishment of a new standard for quantification and comparison of oropharyngeal swallowing impairment across patient diagnoses as measured on MBSS.