A 2-year follow-up of swallowing function after radiation therapy in patients with nasopharyngeal carcinoma

Improvement in Swallowing Function in Patients with Previous Irradiation for Nasopharyngeal Carcinoma by Expiratory Muscle Strength Training

Dysphagia and chronic aspiration are common post-irradiation complications in nasopharyngeal carcinoma (NPC) survivors. Expiratory Muscle Strength Training (EMST) is a simple device-driven exercise therapy for swallowing training. This study investigates the effectiveness of EMST in a group of post-irradiated NPC patients. This prospective cohort, including twelve patients with previous irradiation for NPC and with swallowing disturbance, was performed between 2019 and 2021 in a single institution. Patients were trained with EMST for 8 weeks. Non-parametric analyses examined effects of EMST on primary outcome, maximum expiratory pressure. Secondary outcomes were measured with Penetration-aspiration scale, Yale pharyngeal residue severity rating scale (YPRSRS) by flexible endoscopic evaluation of swallowing, and Eating Assessment Tool (EAT-10) and M.D. Anderson Dysphagia Inventory questionnaire. Twelve patients, with a mean (SD) age of 64.3 (8.2) were recruited. There was no patient dropout with 88.9% overall compliance of training. Maximum expiratory pressure improved by 41% (median 94.5 to 133.5 cmH2O, p = 0.003). There was reduction in Penetration-aspiration scale with thin liquid (median 4 to 3, p = 0.026), and in YPRSRS at pyriform fossa with mildly thick liquid (p = 0.021) and at vallecula with thin liquid (p = 0.034), mildly thick liquid (p = 0.014) and pureed meat congee (p = 0.016). Questionnaire scores did not significantly change statistically. EMST is an easy-to-use and effective exercise therapy to improve airway safety and swallowing function in post-irradiated NPC survivors.

The mediating role of self-efficacy in the association between perceived stigma and psychosocial adjustment: a cross-sectional study among nasopharyngeal cancer survivors

OBJECTIVE

This study aims to examine the levels of and associations between perceived stigma, self-efficacy, and psychosocial adjustment (PA) among nasopharyngeal carcinoma (NPC) survivors, and to identify the mediating role of self-efficacy between stigma and PA and explore the influencing factors of PA.

METHODS

A cross-sectional survey was conducted and 307 NPC survivors were recruited by convenience sampling method in Southern China from July 2019 to January 2020. Data analyses were performed with the SPSS WIN 25.0 program and PROCESS macro version 3.3.

RESULTS

Stigma and self-efficacy were positively associated with PA among Chinese NPC survivors. Tumor-free survival time, late toxicities (fatigue, dizziness and headache, and hearing loss), stigma, and self-efficacy entered the final regression model and explained 55.9% of the variance of PA. The total and direct effects of stigma on PA and its subscales were significant (p < 0.05). Positive indirect effects were found for stigma on PA via self-efficacy (point estimate = 0.159, SE = 0.032, 95% CI [0.102 to 0.229]).

CONCLUSIONS

Stigma and self-efficacy are significantly associated with PA, and self-efficacy is also a mediating variable between stigma and PA among NPC survivors. Medical staff could improve the PA of NPC survivors by alleviating their stigma, enhancing their self-efficacy, and relieving their late toxicities (fatigue, dizziness and headache, and hearing loss).

Stigma, self-efficacy and late toxicities among Chinese nasopharyngeal carcinoma survivors

OBJECTIVE

This study explores the level of stigma among Chinese nasopharyngeal carcinoma survivors, its influencing factors and relationship with self-efficacy.

METHODS

In total, 281 nasopharyngeal carcinoma survivors were recruited from China, who completed the demographic, disease-related and late toxicities questionnaire, as well as the General Self-Efficacy Scale and Social Impact Scale.

RESULTS

The mean scores for stigma and self-efficacy were 57.22 ± 9.58 and 28.06 ± 3.97, respectively, both showing a moderate level. The late toxicities with the highest incidence were xerostomia (91.8%), fatigue (78.3%) and hearing loss (63.0%). Stigma was significantly and negatively related to self-efficacy (r = -0.295, P < 0.001). Multivariable linear regression showed that self-efficacy, number of children, educational level, perceived support from spouse and other family members and some late toxicities (nasal obstruction and toothache) were influencing factors of stigma, accounting for 49.4% of the variance.

CONCLUSION

Medical staff should be more aware of stigma among Chinese nasopharyngeal carcinoma survivors, especially those with more children and weaker educational backgrounds who are at a higher risk of stigma. They should take effective measures to alleviate stigma by improving patients' self-efficacy, relieving late toxicities and encouraging spouses and family members to provide more support for them.

Videofluoroscopic and manometric outcomes of cricopharyngeus balloon dilation for treatment of pharyngo-esophageal dysphagia associated with nasopharyngeal cancer: A case series

BACKGROUND

Problems with pharyngo-esophageal bolus flow have been reported following nasopharyngeal cancer (NPC) treatment. While studies using videofluoroscopic assessment have shown balloon dilation can help address this impairment, the impact of dilation on pressure and bolus flow characteristics incorporating high-resolution pharyngeal manometry (HRPM) has not been reported.

METHODS

Five cases with pharyngo-esophageal dysphagia post NPC underwent balloon dilation. Videofluoroscopic swallowing study (VFSS) and HRPM were completed before and 1 month post dilation. Oral intake and dysphagia related quality of life were reported to 3 months.

RESULTS

VFSS, manometry and functional outcomes revealed positive benefits from dilation in two cases. In the other three cases, two showed improvements on VFSS only. These three failed to make functional swallowing gains.

CONCLUSIONS

Where there was functional gain, both fluoroscopy and HRPM recorded improvement to UES function. Across the cases, response to dilation was variable and further work is needed to determine which patients would receive most benefit.

LEVEL OF EVIDENCE

4.

The Relationships Between Radiation Dosage and Long-term Swallowing Kinematics and Timing in Nasopharyngeal Carcinoma Survivors

This study aimed to investigate the relationship between intensity-modulated radiation therapy (IMRT) dosimetry and swallowing kinematic and timing measures. Thirteen kinematic and timing measures of swallowing from videofluoroscopic analysis were used as outcome measures to reflect swallowing function. IMRT dosimetry was accessed for thirteen swallowing-related structures. A cohort of 44 nasopharyngeal carcinoma (NPC) survivors at least 3 years post-IMRT were recruited. The cohort had a mean age of 53.2 ± 11.9 years, 77.3% of whom were male. There was an average of 68.24 ± 14.15 months since end of IMRT; 41 (93.2%) had undergone concurrent chemotherapy. For displacement measures, female sex and higher doses to the cricopharyngeus, glottic larynx, and base of tongue were associated with reduced hyolaryngeal excursion and pharyngeal constriction, and more residue. For timing measures, higher dose to the genioglossus was associated with reduced processing time at all stages of the swallow. The inferior pharyngeal constrictor emerged with a distinctly different pattern of association with mean radiation dosage compared to other structures. Greater changes to swallowing kinematics and timing were observed for pudding thick consistency than thin liquid. Increasing radiation dosage to swallowing-related structures is associated with reduced swallowing kinematics. However, not all structures are affected the same way, therefore organ sparing during treatment planning for IMRT needs to consider function rather than focusing on select muscles. Dose-response relationships should be investigated with a comprehensive set of swallowing structures to capture the holistic process of swallowing.

Dysphagia after chemo-radiation for nasopharyngeal cancer: A scoping review

Objective

Nasopharyngeal cancer (NPC) has distinct characteristics regarding its global prevalence, initial presentation, management and patient outcomes compared to other subtypes of head and neck cancer (HNC). The mainstay of NPC treatment is chemo-radiation (C/RT) and while dysphagia is a known early and late toxicity of C/RT treatment, the nature of dysphagia post NPC treatment has had limited investigation. The objective of this review is to summarise the existing evidence regarding dysphagia following NPC to inform the future research agenda for this population. Dysphagia incidence, characteristic deficits observed across the phases of swallowing, efficacy of current dysphagia interventions, and effect on quality of life will be explored.

Data sources

Databases including MEDLINE, CINAHL, Embase, Scopus and Web of Science were included.

Methods

A scoping review was conducted according to PRISMA-ScR guidelines. Two independent reviewers screened selected full text articles.

Results

Of the initial 2495 articles found, 28 articles were included. Reports of penetration and aspiration varied widely (0%–91.6%), with high rates of silent aspiration identified in 2 studies (42%, 66%). Oral, pharyngeal and upper esophageal phase impairments were reported. Of these, upper esophageal stasis and multiple pharyngeal stage deficits were most prevalent. The pharyngeal constrictors were found to have a significant dose–effect relationship and shielding to the anterior neck field was effective to preserve swallowing function. Six treatment studies were identified with limited evidence supporting the use of neuromuscular electrical stimulation, dilatation and swallowing exercises. Quality of life was adversely affected.

Conclusions

Dysphagia is a prevalent early and late problem post NPC treatment, with impairments across all phases of the swallow. Studies on preventing dysphagia and treatment efficacy remain limited. More systematic study of the nature of dysphagia and the efficacy of treatment in this population is warranted.

Late Dysphagia Following Radiotherapy After Nasopharyngeal Carcinoma: A Case Series

Purpose Standard treatment for nasopharyngeal carcinoma (NPC) is radiation therapy (RT); however, long-term effects of RT frequently include significant swallowing impairments (dysphagia; Gaziano, 2002; Hui, Chan, & Le, 2018). Our objective was to describe swallowing physiology in consecutive outpatients with a history of NPC following RT using standardized methods. Understanding dysphagia characteristics in this patient population could ultimately inform rehabilitation strategies and improve patient outcomes. Method We conducted a retrospective, observational, descriptive study of consecutive outpatients undergoing videofluoroscopic swallowing (VFS) exams at our clinic, from 2009 to 2014. We included those with a diagnosis of NPC treated with RT. Those with other cancer diagnoses; previous tracheostomy; acute neurological injury; and progressive, degenerative neurological conditions were excluded. Two registered MBSImP clinicians, blinded to each other, reviewed and scored the VFS exams according to previously published methods (Martin-Harris et al., 2008). Following unblinding, a single reviewer collected demographic data from the electronic medical record. We reported overall impairment and MBSImP component scores descriptively. Results Of 158 outpatients undergoing VFS, 6 (N) met our inclusion criteria. The median time from completion of RT to outpatient VFS was 21.0 years. Patients reported a variety of dysphagia symptoms. All patients had high oral and pharyngeal residue scores (scores ≥ 2) and high impairment scores on components contributing to bolus transport and airway closure. Conclusions All patients presented with impairments in oral-pharyngeal bolus transport and airway protection. Our results identify specific swallowing impairments for this patient group highlighting possible latent RT effects on swallowing. This population would benefit from dysphagia rehabilitation and maintenance programs informed by multimodal diagnostic approaches.

Prevalence and Associated Impacts of Cervical Esophageal Clearance Issues Post Chemoradiotherapy for Nasopharyngeal Carcinoma (NPC)

At present, the nature and extent of upper esophageal stage clearance issues following nonsurgical management of nasopharyngeal cancer (NPC) is not well elucidated. The aim of this study was to conduct an initial retrospective study of the prevalence and severity of upper esophageal clearance impairments in a cohort of patients post-NPC management. A secondary aim was to explore any observed relationship between severity of impairment with both (a) aspiration and (b) temporal oropharyngeal swallowing measures. A cohort of 134 NPC patients who received curative intent (chemo)radiotherapy (C/RT) and completed a videofluoroscopic swallowing study (VFSS) between 2012 and 2015 were reviewed. An Esophageal Clearance parameter, based on the scale used in MBSImP was used to classify the presence and severity of esophageal impairment on thin liquid and semisolids. Data on oral and pharyngeal temporal measures, pharyngeal constriction, and penetration/aspiration were also collected. The prevalence of cervical esophageal clearance impairment was high with ratings > 0 observed among 83% and 97% of patients on thin liquid and semisolids, respectively. With the increasing impairment, significantly (p < 0.05) increased oral transit times were observed for liquid swallows, and increased pharyngeal transit times for semisolids. Significantly higher proportions of patients presented with penetration/aspiration in the group with more severe esophageal clearance impairment. Results confirm that cervical esophageal clearance impairment is highly prevalent post-C/RT treatment for NPC. Causality cannot be determined from this study; however, this initial evidence supports that esophageal impairment may coexist in patients post NPC, presenting with more severe oral/pharyngeal deficits, and the impact of this on swallow function needs to be considered. Further systematic research is required.

Radiation-induced late dysphagia after intensity-modulated radiotherapy in nasopharyngeal carcinoma patients: a dose-volume effect analysis

Dysphagia is a side effect of nasopharyngeal carcinoma chemo-radiotherapy (CRT) which greatly influences the quality of life of the patients. We analyzed late dysphagia in 134 patients with nasopharyngeal cancer undergoing radical radiotherapy (RT), and correlated these findings with dose–volume histogram (DVH) parameters of the swallowing organs at risk (SWOARs). DVH parameters of SWOARs were correlated with late dysphagia, and with RTOG/EORTC scale score and the M. D. Anderson dysphagia inventory (MDADI) score. The mean dose (D_mean) to the superior and inferior constrictor muscles (SCM and ICM) and age were associated with grade 2 late dysphagia. Receiver operating characteristic (ROC) curves showed that the threshold values for grade 2 late dysphagia were: D_mean to SCM ≥ 67 Gy, partial volume receiving specified dose of 60 Gy (V₆₀) of SCM ≥ 95%, D_mean to ICM ≥ 47 Gy, and V₅₀ of ICM ≥ 23%. The areas under the ROC curve were 0.681 (p = 0.02), 0.677 (p = 0.002), 0.71 (p < 0.001) and 0.726 (p < 0.001) respectively. Our study demonstrates a significant relationship between late dysphagia and the radiation doses delivered to the SCM and ICM. Our findings suggest that physicians should be cautious in reducing the RT dose to SWOARs in order to avoid severe dysphagia. Further prospective trials are necessary to recommend this as part of routine clinical practice.

Clinical observation and quality of life in terms of nasal sinusitis after radiotherapy for nasopharyngeal carcinoma: long-term results from different nasal irrigation techniques

OBJECTIVE

The aim of our study was to investigate the relationship between nasal irrigation techniques (NIT) and the survival rate and the quality of life (QOL) in patients with nasal sinusitis (NS).

METHODS

We studied data from 1134 patients with nasopharyngeal carcinoma (NPC) who received radical radiotherapy, which were randomly divided into three groups (A, B and C). Group A used nasal irrigator; Group B used homemade nasal irrigation (NI) connector combined with enemator; and Group C used nasal sprayer. The clinical effects, 5-year overall survival (OS) and progression-free survival (PFS) were observed. Furthermore, the QOL in patients with NS was evaluated using the Sino-Nasal Outcome Test 20.

RESULTS

The median follow-up time was 69 months. The 5-year OS and PFS were 80.5% and 73.2%, respectively, for all patients. There was no significant difference in OS, PFS, xerostomia and neck skin toxicity grade 3 and greater among groups. There was no difference among groups. The incidence of NS was the highest in group C.

CONCLUSION

The symptoms of NS seriously affected the QOL period of 1 year. Group C showed no improvement during the follow-up period, which for A and B, by contrast, had after 1 year. Although the exact mechanism remains to be explored in NIT, our findings suggest that patients with NPC should nasal irrigate for 2 years after radiotherapy.

ADVANCES IN KNOWLEDGE

Our study shows that a nasal irrigator is necessary for patients with NPC for a high QOL in terms of NS.