Comprehensive approach to restoration of function in patients with radiation-induced pharyngoesophageal stenosis: Report of 31 patients and proposal of new classification scheme

Impact of Adjuvant Radiotherapy Setting on Quality-of-Life in Head and Neck Squamous Cell Carcinoma

OBJECTIVE

To determine differences in post-treatment QoL across treatment settings in patients receiving adjuvant radiation therapy for head and neck squamous cell carcinoma (HNSCC).

METHODS

This was a prospective observational cohort study of patients with HNSCC initially evaluated in a head and neck surgical oncologic and reconstructive clinic at an academic medical center (AMC). Participants were enrolled prior to treatment in a prospective registry collecting demographic, social, and clinical data. Physical and social-emotional QoL (phys-QoL and soc-QoL, respectively) was measured using the University of Washington-QoL questionnaire at pre-treatment and post-treatment visits.

RESULTS

A cohort of 177 patients, primarily male and White with an average age of 61.2 ± 11.2 years, met inclusion criteria. Most patients presented with oral cavity tumors (n = 132, 74.6%), had non-HPV-mediated disease (n = 97, 61.8%), and were classified as Stage IVa (n = 72, 42.8%). After controlling for covariates, patients treated at community medical centers (CMCs) reported a 7.15-point lower phys-QoL compared with those treated at AMCs (95% CI: -13.96 to -0.35, p = 0.040) up to 12 months post-treatment. Additionally, patients who were treated at CMCs had a 5.77-point (-11.86-0.31, p = 0.063) lower soc-QoL score compared with those treated at an AMC, which was not statistically significant.

CONCLUSION

This study revealed that HNSCC patients treated with radiation at AMCs reported significantly greater phys-QoL in their first-year post-treatment compared to those treated at CMCs, but soc-QoL did not differ significantly. Further observational studies are needed to explore potential factors, including treatment planning and cancer resource engagement, behind disparities between AMCs and CMCs.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:3645-3655, 2024.

Expert Consensus Statement: Management of Dysphagia in Head and Neck Cancer Patients

OBJECTIVE

To develop an expert consensus statement (ECS) on the management of dysphagia in head and neck cancer (HNC) patients to address controversies and offer opportunities for quality improvement. Dysphagia in HNC was defined as swallowing impairment in patients with cancers of the nasal cavity, paranasal sinuses, nasopharynx, oral cavity, oropharynx, larynx, or hypopharynx.

METHODS

Development group members with expertise in dysphagia followed established guidelines for developing ECS. A professional search strategist systematically reviewed the literature, and the best available evidence was used to compose consensus statements targeted at providers managing dysphagia in adult HNC populations. The development group prioritized topics where there was significant practice variation and topics that would improve the quality of HNC patient care if consensus were possible.

RESULTS

The development group identified 60 candidate consensus statements, based on 75 initial proposed topics and questions, that focused on addressing the following high yield topics: (1) risk factors, (2) screening, (3) evaluation, (4) prevention, (5) interventions, and (6) surveillance. After 2 iterations of the Delphi survey and the removal of duplicative statements, 48 statements met the standardized definition for consensus; 12 statements were designated as no consensus.

CONCLUSION

Expert consensus was achieved for 48 statements pertaining to risk factors, screening, evaluation, prevention, intervention, and surveillance for dysphagia in HNC patients. Clinicians can use these statements to improve quality of care, inform policy and protocols, and appreciate areas where there is no consensus. Future research, ideally randomized controlled trials, is warranted to address additional controversies related to dysphagia in HNC patients.

Three dimensional condylar positional and morphological changes following mandibular reconstruction based on CBCT analysis: a prospective study

OBJECTIVE

This study aimed to evaluate the condylar positional changes following mandibular reconstruction with preservation of the condylar head using Cone-Beam Computed Tomography (CBCT). Also, to assess joint space changes and the overall volumetric space compared to the preoperative status.

METHODOLOGY

This prospective study included 30 patients (60 joints) subjected to unilateral mandibular resection and reconstruction with preservation of the condylar head. The Helkimo index and preoperative (T1), two weeks postoperative (T2), and follow-up CBCTs (T3) after at least six months were gathered and processed to evaluate the condylar position and TMJ joint space using Anatomage Invivo 6. A student's t-test and repeated-measures ANOVA statistics were used. A P value of less than 0.05 was considered statistically significant.

RESULTS

Thirty patients (14 males, 16 females) with a mean age of 40.01 ± 12.7 years (a range of 18.1-62.9 years) were included. On the tumor side, there were significant variances in the vertical and mediolateral condylar positions between the three-time points (T1, T2, T3). Immediately after the operation, the condyles were significantly displaced in a downward direction at T2, which became larger after the last follow-up period (T3) (p = 0.007). The condylar positions at the anteroposterior direction were relatively stable without significant differences between the three times points (p = 0.915). On the non-tumor side, the condylar positions were relatively stable in the mediolateral and anteroposterior positions. In the tumor side, all of the TMJ spaces were significantly increased in size following the mandibular reconstructions (T2 and T3). However, on the non-tumor side, the anterior, posterior, and medial joint spaces were significantly changed postoperatively.

CONCLUSION

After mandibular reconstruction with condylar preservation, the condylar position and volumetric measurement immediately changed noticeably and continued to be a permanent change over time compared to relatively stable condyles on the non-tumor side. According to Helkimo index, patients become adapted to the postoperative changes without significant differences between the two sides.

Diagnosis and management of pharyngoesophageal stenosis: A comprehensive approach to prophylactic, endoscopic, and reconstructive treatment options

BACKGROUND

Pharyngoesophageal stenosis (PES) is a serious complication that substantially impacts functional outcomes and quality of life (QOL) for up to a third of head and neck cancer patients who undergo radiotherapy. Dysphagia is often multifactorial in nature and is a devastating complication of treatment that impacts patients' QOL, general health and overall wellbeing. The authors detail the clinical presentation, risk factors, imaging characteristics, preventive measures, and multimodality treatment options for PES.

METHODS

The authors present a comprehensive management algorithm for PES, including treatment by dilation, stenting, spray cryotherapy and dilation, and reconstructive treatment options utilizing different pedicled and free flaps.

RESULTS

The authors advocate for a thorough assessment of the extent and degree of pharyngoesophageal involvement of PES to determine the optimal management strategy.

CONCLUSIONS

The development of post treatment dysphagia requires appropriate imaging and biopsy, when indicated, to rule out the presence of persistent/recurrent cancer. Multidisciplinary management by a team of physicians well-versed in the range of diagnostic and therapeutic interventions available for PES is critical to its successful management.

Late side effects of radiation treatment for head and neck cancer

Patients undergoing radiation therapy for head and neck cancer (HNC) experience significant early and long-term side effects. The likelihood and severity of complications depends on a number of factors, including the total dose of radiation delivered, over what time it was delivered and what parts of the head and neck received radiation. Late side effects include: permanent loss of saliva; osteoradionecrosis; radiation recall myositis, pharyngoesophageal stenosis; dental caries; oral cavity necrosis; fibrosis; impaired wound healing; skin changes and skin cancer; lymphedema; hypothyroidism, hyperparathyroidism, lightheadedness, dizziness and headaches; secondary cancer; and eye, ear, neurological and neck structures damage. Patients who undergo radiotherapy for nasopharyngeal carcinoma tend to suffer from chronic sinusitis. These side effects present difficult challenges to the patients and their caregivers and require life-long strategies to alleviate their deleterious effect on basic life functions and on the quality of life. This review presents these side effects and their management.

The Sternocleidomastoid Myocutaneous Flap: A Laryngeal Preservation Option for Total Hypopharyngoesophageal Stenosis

Complete hypopharyngoesophageal (HPE) stenosis is rare and a challenging condition to treat. When endoscopic therapy fails, total laryngectomy with or without pharyngeal reconstruction is usually performed. We present a retrospective case series involving 3 patients with complete HPE stenosis who failed endoscopic repair and were gastrostomy dependent. All were managed successfully with the sternocleidomastoid myocutaneous (SCM) flap. A temporary fistula occurred in 1 patient. Hospitalization ranged from 5 to 15 days, patients resumed oral intake from 21 to 82 days postoperatively, and their gastrostomy tubes were removed from 28 to 165 days postoperatively. We suggest that the SCM flap is a laryngeal preservation option for reconstruction of complete HPE stenosis when endoscopic techniques fail. This flap allows HPE repair and reconstruction within the same surgical field, imposes no significant donor site morbidity, and affords good functional and cosmetic outcomes.

Endoscopic Management of Postradiation Dysphagia in Head and Neck Cancer Patients: A Systematic Review

OBJECTIVES

To systematically review the success rate and safety profile of the available endoscopic surgical options for radiation-induced dysphagia in head and neck cancer patients following organ preservation treatment, including upper esophageal sphincter (UES) dilation, cricopharyngeus (CP) myotomy (CPM), and CP intramuscular botulinum toxin (Botox) injection.

METHODS

A search of MEDLINE, Scopus, Google Scholar, and Cochrane databases was done to identify articles published between January 1980 and December 2017. Pediatric series, foreign language articles, series with Zenker's diverticulum or following primary surgical treatment including laryngectomy, open UES/CP surgery, or samples with fewer than 5 patients were excluded.

RESULTS

An initial search identified 539 articles. All titles and abstracts were reviewed. One hundred and sixteen potentially relevant articles were inspected in more detail, and 14 retrospective studies met eligibility criteria. Dilation group included 10 studies on anterograde and/or retrograde dilation, with an overall 208 patients. Success rate ranged from 42% to 100%. The endoscopic CPM group included 3 studies with a total of 36 patients, and the success rate ranged from 27% to 90%. In the Botox group, 1 one study with 20 patients met our inclusion criteria, with an overall 65% success rate (13/20). Major complications were only reported in the dilation group, which included esophageal perforation and death.

CONCLUSIONS

The lack of consistency across trials indicates insufficient evidence for guiding clinical practice. This systematic review suggests the need for greater standardization of outcomes and instruments. Future prospective evaluation should use validated patient-rated and clinician-rated assessment tools to optimally measure postoperative swallowing outcomes of head and neck cancer dysphagic patients following organ preservation therapy.

Endoscopic Injection of Mitomycin C for the Treatment of Pharyngoesophageal Stenosis Refractory to Endoscopic Treatment with Dilatation in Patients Treated for Head and Neck Cancer

Background

Management of pharyngoesophageal stenosis (PES) in patients after head and neck cancer (HNC) treatment remains a challenge. It is not uncommon that PES is refractory to dilation sessions. This study aimed at evaluating the efficacy of Mitomycin C (MMC) endoscopic injection for the treatment of refractory pharyngoesophageal stenosis.

Patients and methods

This is a prospective study in patients with dysphagia following head and neck cancer treatment, without evidence suggestive of tumor recurrence, and refractory to endoscopic treatment. These patients were submitted to endoscopic dilation of the stenotic segment with thermoplastic bougies, followed by injection of MMC. We repeated the endoscopic sessions every three weeks.

Results

From January 2015 to May 2015, we treated 13 patients with PES. Three patients were initially enrolled in the study for refractory stricture. We observed adverse events in all of them, with intense neck pain and ulcer development, justifying the interruption of the trial.

Conclusion

The repeated injection in the short interval of MMC in refractory PES is not recommended, because it resulted in serious adverse events.

Esophagram findings in cervical esophageal stenosis: A case-controlled quantitative analysis

OBJECTIVE

Cervical esophageal stenosis is often diagnosed with a qualitative evaluation of a barium esophagram. Although the esophagram is frequently the initial screening exam for dysphagia, a clear objective standard for stenosis has not been defined. In this study, we measured esophagram diameters in order to establish a quantitative standard for defining cervical esophageal stenosis that requires surgical intervention.

STUDY DESIGN

Single institution case-control study.

METHODS

Patients with clinically significant cervical esophageal stenosis defined by moderate symptoms of dysphagia (Functional Outcome Swallowing Scale > 2 and Functional Oral Intake Scale < 6) persisting for 6 months and responding to dilation treatment were matched with age, sex, and height controls. Both qualitative and quantitative barium esophagram measurements for the upper, mid-, and lower vertebral bodies of C5 through T1 were analyzed in lateral, oblique, and anterior-posterior views.

RESULTS

Stenotic patients versus nonstenotic controls showed no significant differences in age, sex, height, body mass index, or ethnicity. Stenosis was most commonly at the sixth cervical vertebra (C 6) lower border and C7 upper border. The mean intraesophageal minimum/maximum ratios of controls and stenotic groups in the lateral view were 0.63 ± 0.08 and 0.36 ± 0.12, respectively (P < 0.0001). Receiver operating characteristic analysis of the minimum/maximum ratios, with a <0.50 ratio delineating stenosis, demonstrated that lateral view measurements had the best diagnostic ability. The sensitivity of the radiologists' qualitative interpretation was 56%. With application of lateral intraesophageal minimum/maximum ratios, we observed improved sensitivity to 94% of the esophagram, detecting clinically significant stenosis.

CONCLUSION

Applying quantitative determinants in esophagram analysis may improve the sensitivity of detecting cervical esophageal stenosis in dysphagic patients who may benefit from surgical therapy.

LEVEL OF EVIDENCE

IIIb. Laryngoscope, 128:2022-2028, 2018.

Speech and swallow rehabilitation in head and neck cancer: United Kingdom National Multidisciplinary Guidelines

This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. The disease itself and the treatment can have far reaching effects on speech and swallow function, which are consistently prioritised by survivors as an area of concern. This paper provides recommendations on the assessments and interventions for speech and swallow rehabilitation in this patient group.

Prevention and management of treatment-induced pharyngo-oesophageal stricture

Pharyngo-oesophageal stricture (PES) is a serious complication that occurs in up to a third of patients treated with external beam radiotherapy or combined chemoradiotherapy for head and neck cancer. This entity is under-reported and as a result, our understanding of the pathophysiology and prevention of this complication is restricted. This Review presents the knowledge so far on radiation-related and non-radiation-related risk factors for PES, including tumour stage and subsite, patient age, and comorbidities. The interventions to decrease this toxicity are discussed, including early detection of PES, initiation of an oral diet, and protection of swallowing structures from high-dose radiation. We discuss various treatment options, including swallowing exercises and manoeuvres, endoscopic dilatations, and for advanced cases, oesophageal reconstruction. Study of the subset of patients who develop this toxicity and early recognition and intervention of this pathological change in future trials will help to optimise treatment of these patients.