Swallowing disorders in head and neck cancer patients treated with radiotherapy and adjuvant chemotherapy

Breathing-Swallowing discoordination after definitive chemoradiotherapy for head and neck cancers is associated with aspiration pneumonia

PURPOSE

Swallowing dysfunction and the risk of aspiration pneumonia are frequent clinical problems in the treatment of head and neck squamous cell carcinomas (HNSCCs). Breathing-swallowing coordination is an important factor in evaluating the risk of aspiration pneumonia. To investigate breathing-swallowing discoordination after chemoradiotherapy (CRT), we monitored respiration and swallowing activity before and after CRT in patients with HNSCCs.

METHODS

Non-invasive swallowing monitoring was prospectively performed in 25 patients with HNSCCs treated with CRT and grade 1 or lower radiation-induced dermatitis. Videoendoscopy, videofluoroscopy, Food Intake LEVEL Scale, and patient-reported swallowing difficulties were assessed.

RESULTS

Of the 25 patients selected for this study, four dropped out due to radiation-induced dermatitis. The remaining 21 patients were analyzed using a monitoring system before and after CRT. For each of the 21 patients, 405 swallows were analyzed. Swallowing latency and pause duration after the CRT were significantly extended compared to those before the CRT. In the analysis of each swallowing pattern, swallowing immediately followed by inspiration (SW-I pattern), reflecting breathing-swallowing discoordination, was observed more frequently after CRT (p = 0.0001). In 11 patients, the SW-I pattern was observed more frequently compared to that before the CRT (p = 0.00139). One patient developed aspiration pneumonia at 12 and 23 months after the CRT.

CONCLUSION

The results of this preliminary study indicate that breathing-swallowing discoordination tends to increase after CRT and could be involved in aspiration pneumonia. This non-invasive method may be useful for screening swallowing dysfunction and its potential risks.

Prognosis of Pneumonia in Head and Neck Squamous Cell Carcinoma Patients Who Received Concurrent Chemoradiotherapy

Concurrent chemoradiotherapy (CCRT) is the standard treatment for patients with locally advanced squamous cell carcinoma of the head and neck (HNSCC). Pneumonia is a significant complication in these patients. This study aims to identify pneumonia risk factors and their impact on survival in HNSCC patients undergoing CCRT. Data from the Chang Gung Research Database (CGRD) were retrospectively reviewed for patients treated between January 2007 and December 2019. Of 6959 patients, 1601 (23.01%) developed pneumonia, resulting in a median overall survival (OS) of 1.2 years compared to 4.9 years in the non-pneumonia group (p < 0.001). The pneumonia group included older patients with advanced tumors, more patients with diabetes mellitus (DM), more patients with invasive procedures, longer chemotherapy and radiotherapy durations, and lower body weight. The 2-year, 5-year, and 10-year OS rates were significantly lower in the pneumonia group. Multivariate analysis identified alcohol consumption, DM, gastrostomy, nasogastric tube use, longer chemotherapy, and a 2-week radiotherapy delay as independent risk factors. Understanding these risks can lead to early interventions to prevent severe pneumonia-related complications. A better understanding of the risks of pneumonia enables early and aggressive interventions to prevent severe complications.

Chemoradiation to the submental muscles alters hyoid movement during swallowing in a rat model

Hyolaryngeal dysfunction is a commonly reported swallowing problem after chemoradiation treatment for head and neck cancer. The displacement of the hyolaryngeal complex during swallowing protects the airway and assists in opening the upper esophageal sphincter. Activation of the submental muscles, specifically the mylohyoid and geniohyoid muscles, is thought to facilitate movement of the hyoid. The purpose of this study was to determine if targeted radiation to the submental muscles given concurrently with chemotherapy alters hyolaryngeal displacement 1 mo after treatment. We hypothesized that chemoradiation treatment would result in abnormal patterns of hyoid movement compared with controls. Furthermore, we propose that these changes are associated with alterations in bolus size and discoordination of the jaw during drinking. Eighteen rats underwent either chemoradiation, radiation, or no treatment. Radiation treatment was targeted to submental muscles using a clinical linear accelerator given in 12 fractions of 4 Gy (3 days per week). Cycles of 1 mg/kg of cisplatin were administered concurrently each week of radiation. One month posttreatment, videofluoroscopy swallow studies (VFSS) were performed in self-drinking rats using a fluoroscope customized with a high-speed camera. The hyoid, jaw, and hard palate were tracked during swallowing from VFSS. Hyoid kinematics were analyzed from the start to the end of hyoid movement, and parameters were compared with bolus size and jaw movement. Significant differences in hyoid retraction parameters were found postchemoradiation. Alterations in the trajectory of hyoid motion during swallowing were observed. The findings demonstrate early changes in hyoid motion during swallowing associated with chemoradiation treatment.NEW & NOTEWORTHY Chemoradiation treatment for head and neck cancer can cause functional impairments in swallowing, which can adversely affect quality of life. This study provides new evidence that chemoradiation targeted to the submental muscles provokes early adaptations in hyoid movement during swallowing, which correlate with changes in bolus size. We also demonstrate a method for tracking the hyoid during swallowing in a rat model of chemoradiation injury.

The regulation of expression and splicing of transcription factors are related to the muscle damage caused by radiation in tree shrews

Radiotherapy-induced muscle injury (RIMI) is a major complication of radiotherapy for nasopharyngeal carcinoma. Transcription factor (TF) expression and alternative splicing are crucial events in transcriptional and posttranscriptional regulation, respectively, and are known to be involved in key signaling pathways contributing to a variety of human disorders, including radiation injury. To investigate the TFs and alternative splicing events involved in RIMI, we constructed a tree shrew model as described previously in which the RIMI group received 20 Gy of irradiation on the tensor veli palatini (TVP) muscles. The irradiated muscles were evaluated by RNA sequencing (RNA-seq) 6 months later, and the results compared with those for normal TVP muscles. The alt5p and alt3p events were the two main types of differentially regulated alternative splicing events (RASEs) identified via the Splice sites Usage Variation Analysis (SUVA) software, and these RASEs were highly conserved in RIMI. According to functional enrichment analysis, the differentially RASEs were primarily enriched in pathways related to transcriptional regulation. Furthermore, we identified 16 alternative splicing TFs (ASTFs) in ASTF-differentially expressed gene (DEG) networks based on co-expression analysis, and the regulatory networks were chiefly enriched in pathways linked to cell proliferation and differentiation. This study revealed that RASEs and ASTF-DEG networks may both play important regulatory roles in gene expression network alteration in RIMI. Future studies on the targeting mechanisms and early interventions directed at RASEs and ASTF-DEG networks may aid in the treatment of RIMI.

Impact of Dynamic Tongue Reconstruction on Sequential Changes of Swallowing Function in Patients Undergoing Total or Near-Total Glossectomy

PURPOSE

This study aimed to compare the effects of motor-innervated free flap on sequential changes of swallowing function in patients undergoing total or near-total glossectomy with laryngeal preservation.

MATERIALS AND METHODS

The medical charts of 21 patients who underwent tongue reconstruction after total or near-total glossectomy between April 2015 and December 2020 were retrospectively reviewed. Patients were divided into groups by reconstruction type: conventional, reconstruction using an anterolateral thigh free flap (n = 11), and dynamic, reconstruction using an anterolateral thigh with innervated vastus lateralis flap (n = 10). Demographics, surgical details, and survival outcomes were investigated. A videofluoroscopic penetration-aspiration scale and functional outcome swallowing scale were analyzed according to postoperative time courses, classified as within 6 months, 6 to 12 months, and after 12 months postoperative. A time-to-event analysis was performed for gastrostomy tube status.

RESULTS

The dynamic group showed improved swallowing outcomes at 6 to 12 months postoperative (dynamic vs conventional group, penetration-aspiration scale: 3 ± 1.51 vs 6 ± 1.63, P = 0.024; functional outcome swallowing scale: 1.89 ± 1.36 vs 4 ± 1.41, P = 0.009). In the multivariate analysis, the dynamic group showed a decreased probability of decompensated swallowing function at 6 to 12 months postoperative (odds ratio, 0.062; 95% confidence interval, 0.004-1.084; P = 0.057). A time-to-event analysis revealed no significant difference in gastrostomy tube status between the dynamic and the conventional group.

CONCLUSIONS

Considering higher mortality in patients subjected to total or near-total glossectomy, dynamic reconstruction with motor-innervated free flap is worth to perform in terms of enhancing the swallowing function within 1-year postoperative period, thereby improving the quality of life.

Radiation induced changes in profibrotic markers in the submental muscles and their correlation with tongue movement

Swallowing impairment is a major complication of radiation treatment for oropharyngeal cancers. Developing targeted therapies that improve swallowing outcomes relies on an understanding of the mechanisms that influence motor function after radiation treatment. The purpose of this study was to determine whether there is a correlation between radiation induced changes in tongue movement and structural changes in irradiated submental muscles, as well as assess other possible causes for dysfunction. We hypothesized that a clinically relevant total radiation dose to the submental muscles would result in: a) quantifiable changes in tongue strength and displacement during drinking two months post treatment; and b) a profibrotic response and/or fiber type transition in the irradiated tissue. Sprague-Dawley adult male rats received radiation to the submental muscles at total dose-volumes known to provoke dysphagia in humans. A clinical linear accelerator administered 8 fractions of 8Gy for a total of 64Gy. Comparisons were made to sham-treated rats that received anesthesia only. Swallowing function was assessed using videofluoroscopy and tongue strength was analyzed via force lickometer. TGFβ1 expression was analyzed via ELISA. The amount of total collagen was analyzed by picrosirius red staining. Immunofluorescence was used to assess fiber type composition and size. Significant changes in licking function during drinking were observed at two months post treatment, including a slower lick rate and reduced tongue protrusion during licking. In the mylohyoid muscle, significant increases in TGFβ1 protein expression were found post radiation. Significant increases in the percentage of collagen content were observed in the irradiated geniohyoid muscle. No changes in fiber type expression were observed. Results indicate a profibrotic transition within the irradiated swallowing muscles that contributes to tongue dysfunction post-radiation treatment.

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.

Longitudinal Analysis of Swallowing Displacement Kinematics After Oropharyngeal Cancer Treatment

BACKGROUND/OBJECTIVE

Quantitative swallowing displacement kinematics evolve in patients treated for oropharyngeal squamous cell carcinoma (OPSCC). We aimed to longitudinally assess these measurements and correlate them with functional swallowing outcomes.

METHOD

A retrospective review was conducted on patients with OPSCC treated with definitive (chemo)radiation ([C]RT) or surgery with adjuvant (chemo)radiation (S-[C]RT) who completed at least two videofluoroscopic swallow studies (VFSS). Longitudinal analysis was accomplished via mixed-effects logistic regression for the Functional Oral Intake Scale (FOIS), and Penetration Aspiration Scale (PAS), and mixed-effects linear regression for kinematic measures. Spearman's correlation was conducted between changes in FOIS/PAS and kinematic measures.

RESULTS

Ninety-seven patients (76 males; mean age 61) completed 245 VFSS studies. A total of 94% had human papillomavirus (HPV)/p16 positive OPSCC and 74% were T0-T2. Sixty-four patients underwent [C]RT while 33 patients underwent S-[C]RT. After treatment, posterior pharyngeal wall at hold (PPWhold) increased 3.2 standard deviation (SD) between 0 and 6 months (p < 0.001), then decreased 2.2 SD between 6 and 12 months (p < 0.001) and did not return to baseline. Hyoid-to-larynx (HL) (p = 0.046) and maximal hyoid displacement (Hmax) + HL (p = 0.042) increased between 6 and 12 months. Hmax (p = 0.020) and Hmax + HL (p < 0.001) decreased between 12-24 months beyond baseline values. The decrease in HL and increase in PPWhold (p < 0.05) correlated with an increase in PAS. From baseline, increased pharyngeal constriction ratio correlated with decreased FOIS and PPWhold (p < 0.05).

CONCLUSIONS

Quantitative swallowing kinematic measures can effectively track changes in swallowing physiology. Increased PPWhold and restricted hyolaryngeal movement were seen in patients with OPSCC after treatment and correlated with a change in swallowing outcome, emphasizing the need for serial VFSS monitoring and targeted intervention.

LEVEL OF EVIDENCE

3 Laryngoscope, 2022.

Acute effects of radiation treatment to submental muscles on burrowing and swallowing behaviors in a rat model

Swallowing impairments are a major complication of radiation treatment for oropharyngeal cancers, influencing oral intake and quality of life. The timing and functional consequences of radiation treatment on the swallowing process is not clearly understood. A rodent radiation injury model was used to investigate the onset of oral and pharyngeal dysfunctions in deglutition related to radiation treatment. This study tested the hypothesis that (Wall et al., 2013) alterations in normal biting, licking, and swallowing performance would be measurable following 64Gy of fractionated radiation to the submental muscles; and (Kotz et al., 2004) radiation will affect the animal’s general well-being as measured via burrowing activity. Seven rats received radiation using a clinical linear accelerator given in 8 fractions of 8Gy and another seven animals received sham anesthesia only treatment. Swallowing bolus transit/size was assessed via videofluoroscopy, tongue movement during drinking was measured via an electrical lick sensor, and biting was analyzed from acoustic recordings of a vermicelli pasta test. Burrowing activity was measured by the amount of gravel substrate displaced within a container. Measurements were taken at baseline, during treatment (1–4 weeks), and after completion of treatment (weeks 5 & 6). Decreases in licking frequency and increases in inter-lick interval were observed 5- and 6-weeks post-treatment. Significant decreases in burrowing performance, swallowing frequency, and inter-swallow interval were observed starting the last week of treatment and continuing up to 2-weeks after completion. Results suggest that tongue dysfunction is one of the first treatment related feeding problems to present immediately after the completion of radiation to the submental muscles.

Predictors of severe dysphagia following radiotherapy for head and neck cancer

OBJECTIVE

To investigate if severe dysphagia following radiotherapy for head and neck cancer (HNC) could be predicted by patient and tumor characteristics, feeding tube use, weight factors, jaw opening function, and saliva secretion.

METHODS

Data was collected from 94 HNC patients 6 to 36 months post radiotherapy. Swallowing function was assessed by videofluroscopy (VFS). Severe dysphagia was defined by Penetration Aspiration Scale (PAS) as PAS≥5 or a total score ≤60 on the M. D. Anderson Dysphagia Inventory (MDADI).

RESULTS

Thirty-three patients (35%) had PAS ≥5 and 19 (20%) a MDADI ≤60, that is, presented with severe dysphagia. Univariable logistic regression analysis (UVA) gave that tumor of the tonsil, overweight at time of VFS and each unit increase in Body Mass Index (BMI) predicted less risk of PAS ≥5. Dependency of feeding tube at time of VFS and each month's continued use and weight loss ≥7.5% since treatment to time of VFS predicted increased risk of PAS ≥5. Predictive variables from the UVA of PAS ≥5 (tumor of the tonsil, overweight, and total duration of feeding tube), were analyzed by multivariate logistic regression analysis. All retained power as independent predictors. UVA for MDADI showed that use of feeding tube at time of VFS predicted MDADI ≤60 with the risk increasing each month. Each increasing unit of BMI decreased risk of MDADI ≤60.

CONCLUSION

Long time users of feeding tube and higher weight-loss are at risk of severe dysphagia. This makes collaboration between professionals working with dysphagia an important step in detecting severe dysphagia.Level of Evidence: 3.

Fluoroscopic Swallowing Examination: Radiologic Findings and Analysis of Their Causes and Pathophysiologic Mechanisms

Dysphagia is a common symptom in the general population, and its prevalence increases with patient age. The deterioration of swallowing function has many acute and chronic causes, including cerebrovascular and neuromuscular diseases, radiation, and surgery. In an elderly population, diagnosis and treatment of swallowing abnormalities is a high priority because it improves the patient's quality of life and helps them to avoid medical complications. Fluoroscopic swallowing examinations and modified barium swallow studies are the most used and most reliable diagnostic procedures to evaluate swallowing disorders. Functional anomalies include disturbances of the oral preparatory, oral propulsory, and pharyngeal phases of swallowing as premature spillage from the mouth, nasal regurgitation, delayed initiation of pharyngeal swallowing, incomplete displacement of the hyolaryngeal complex, abnormal epiglottic tilt, incomplete laryngeal closure, and pharyngeal dysmotilities. Anatomic abnormalities of the pharynx include diverticula, benign strictures, and tumors. The abnormalities diagnosed on the basis of fluoroscopic examination have a variety of treatment strategies, and the choice of treatment depends on the cause of the anomaly and its pathophysiologic characteristics. The radiologist's interpretation of these characteristics is crucial to therapeutic decision making and achieving the best patient outcomes. Online supplemental material is available for this article. ^©RSNA, 2021.

Sequential Evaluation of Swallowing Function During Chemoradiotherapy for Head and Neck Cancer

Background

Many studies have addressed chronic dysphagia resulting from chemoradiotherapy for head and neck cancer (HNC) because of its severity, but changes in the swallowing function during chemoradiotherapy has been rarely reported. This study aimed to elucidate the changes in the swallowing function during chemoradiotherapy for HNC.

Methods

From April 2018 to July 2020, 20 patients who underwent definitive or postoperative chemoradiotherapy at our hospital for head and neck squamous cell carcinoma were evaluated by flexible endoscopy with the Hyodo scoring system for swallowing, the Penetration-Aspiration Scale (PAS), and the Functional Outcomes Swallowing Scale (FOSS).

Results

Assessments at the start of treatment, at 40 Gy, and at the end of treatment yielded these mean values: Hyodo score-0.39, 1.22, and 2.56; PAS-1.00, 1.05, and 1.5; FOSS-0.2, 0.55, and 1.1, respectively. The Dunn multiple comparison test was used for analysis to determine significance (P < 0.05). The Hyodo score and FOSS were significantly increased at the end of treatment versus initial evaluation; however, score was maintained at a tolerable level for oral intake. PAS did not show a significant increase.

Conclusion

In conclusion, changes in the swallowing function during chemoradiotherapy for HNC were mild, and swallowing function was maintained at a tolerable level for oral intake.

Determining the Impact of Thickened Liquids on Swallowing in Patients Undergoing Irradiation for Oropharynx Cancer

The current standard for the treatment of oropharynx cancers is radiation therapy. However, patients are frequently left with dysphagia characterized by penetration-aspiration (impaired safety) and residue (impaired efficiency). Although thickened liquids are commonly used to manage dysphagia, we lack evidence to guide the modification of liquids for clinical benefit in the head and neck cancer population. The objective of this study was to assess the impact of slightly and mildly thick liquids on penetration-aspiration and residue in 12 patients with oropharyngeal cancer who displayed penetration-aspiration on thin liquid within 3 to 6 months after completion of radiotherapy. Significantly fewer instances of penetration-aspiration were seen with slightly and mildly thick liquids as compared with thin (P < .05). No differences were found across stimuli in the frequency of residue. Patients with oropharyngeal cancers who present with post-radiation therapy dysphagia involving penetration-aspiration on thin liquids may benefit from slightly and mildly thick liquids without risk of worse residue.

Respiratory-swallow coordination and swallowing impairment in head and neck cancer

BACKGROUND

The aim of the study was to determine the link between frequency of optimal respiratory-swallow coordination, swallowing impairment, and airway invasion in head and neck cancer (HNC) patients.

METHOD

A cross-sectional study of a heterogeneous group of HNC patients (49), precancer (N = 30) or postcancer treatment (N = 29), participated in a single Modified Barium Swallow Study (MBSS) with synchronized respiratory data.

RESULTS

Spearman correlation coefficients revealed significant negative correlations between optimal respiratory-swallow phase pattern and objective measures of swallowing impairment: penetration-aspiration scale max, pharyngeal total, and oral total scores with Spearman correlation coefficients of -0.53 (z .001), -0.50 (P < .001), and -0.43 (P = .002), respectively. Optimal respiratory-swallow pattern was significantly decreased (P = .03) in patients after cancer treatment compared with another patient group before cancer treatment.

CONCLUSION

These findings indicate that as the percentage of optimal respiratory-swallow phase patterns increase, swallowing impairment decreases in the HNC patient population.

Swallowing dysfunction following radiation to the rat mylohyoid muscle is associated with sensory neuron injury

Radiation-based treatments for oropharyngeal and hypopharyngeal cancers result in impairments in swallowing mobility, but the mechanisms behind the dysfunction are not clear. The purpose of this study was to determine if we could establish an animal model of radiation-induced dysphagia in which mechanisms could be examined. We hypothesized that 1) radiation focused at the depth of the mylohyoid muscle would alter normal bolus transport and bolus size and 2) radiation to the mylohyoid muscle will induce an injury/stress-like response in trigeminal sensory neurons whose input might modulate swallow. Rats were exposed to 48 or 64 Gy of radiation to the mylohyoid given 8 Gy in 6 or 8 fractions. Swallowing function was evaluated by videofluoroscopy 2 and 4 wk following treatment. Neuronal injury/stress was analyzed in trigeminal ganglion by assessing activating transcription factor (ATF)3 and GAP-43 mRNAs at 2, 4, and 8 wk post treatment. Irradiated rats exhibited decreases in bolus movement through the pharynx and alterations in bolus clearance. In addition, ATF3 and GAP-43 mRNAs were upregulated in trigeminal ganglion in irradiated rats, suggesting that radiation to mylohyoid muscle induced an injury/stress response in neurons with cell bodies that are remote from the irradiated tissue. These results suggest that radiation-induced dysphagia can be assessed in the rat and radiation induces injury/stress-like responses in sensory neurons.NEW & NOTEWORTHY Radiation-based treatments for head and neck cancer can cause significant impairments in swallowing mobility. This study provides new evidence supporting the possibility of a neural contribution to the mechanisms of swallowing dysfunction in postradiation dysphagia. Our data demonstrated that radiation to the mylohyoid muscle, which induces functional deficits in swallowing, also provokes an injury/stress-like response in the ganglion, innervating the irradiated muscle.

Speech-Language Pathology Guidance for Tracheostomy During the COVID-19 Pandemic: An International Multidisciplinary Perspective

Purpose As the COVID-19 pandemic has unfolded, there has been growing recognition of risks to frontline health care workers. When caring for patients with tracheostomy, speech-language pathologists have significant exposure to mucosal surfaces, secretions, and aerosols that may harbor the SARS-CoV-2 virus. This tutorial provides guidance on practices for safely performing patient evaluation and procedures, thereby reducing risk of infection. Method Data were collated through review of literature, guidelines, and consensus statements relating to COVID-19 and similar high-consequent infections, with a focus on mitigating risk of transmission to health care workers. Particular emphasis was placed on speech-language pathologists, nurses, and other allied health professionals. A multinational interdisciplinary team then analyzed findings, arriving at recommendations through consensus via electronic communications and video conference. Results Reports of transmission of infection to health care workers in the current COVID-19 pandemic and previous outbreaks substantiate the need for safe practices. Many procedures routinely performed by speech-language pathologists have a significant risk of infection due to aerosol generation. COVID-19 testing can inform level of protective equipment, and meticulous hygiene can stem spread of nosocomial infection. Modifications to standard clinical practice in tracheostomy are often required. Personal protective equipment, including either powered air-purifying respirator or N95 mask, gloves, goggles, and gown, are needed when performing aerosol-generating procedures in patients with known or suspected COVID-19 infection. Conclusions Speech-language pathologists are often called on to assist in the care of patients with tracheostomy and known or suspected COVID-19 infection. Appropriate care of these patients is predicated on maintaining the health and safety of the health care team. Careful adherence to best practices can significantly reduce risk of infectious transmission.

Cytokine and Growth Factor Response in a Rat Model of Radiation Induced Injury to the Submental Muscles

Submental muscles (i.e., mylohyoid and geniohyoid) play a vital role during swallowing, protecting the airway from ingested material. To design therapies to reduce the functional deficits associated with radiation treatment relies in part on our understanding of the changes in the cytokine and growth factor response that can impact muscle function. The purpose of this study is to quantify changes in the inflammatory, pro-fibrotic, and pro-angiogenic factors following 48 Gy of fractionated radiation to the mylohyoid muscle. We hypothesized that (1) irradiation will provoke increases in TGF-1β and MMP-2 mRNA in the mylohyoid muscle; and (2) muscles surrounding the target location (i.e., geniohyoid and digastric muscles) will exhibit similar alterations in their gene expression profiles. Rats were exposed to 6 fractions of 8 Gy using a 6 MeV electron beam on a clinical linear accelerator. The highest dose curve was focused at the mylohyoid muscle. After 2- and 4-weeks post-radiation, the mylohyoid, geniohyoid, and digastric muscles were harvested. Expression of TNF-α, IFNγ, IL-1β, IL-6, TGF-1β, VEGF, MMP-2, and MMP-9 mRNA was analyzed via PCR and/or RT-PCR. TGF-1β, MMP-2, and IL-6 expression was upregulated in the irradiated mylohyoid compared to non-irradiated controls. No notable changes in TNF-α, IFNγ, and IL-1β mRNA expression were observed in irradiated muscles. Differing expression profiles were found in the surrounding muscles post-radiation. Results demonstrated that irradiation provokes molecular signals involved in the regulation of wound healing, which could lead to fibrosis or atrophy in the swallowing muscle after radiation.

Factors Influencing the Development of Pneumonia in Patients With Head and Neck Cancer: A Meta-analysis

Objective

The aim of this study was to identify factors that are associated with the occurrence of pneumonia in patients with head and neck cancer (HNC) after treatment.

Data Sources

PubMed, Scopus, OVID, and Cochrane Library from inception to November 26, 2019.

Review Methods

A systematic review in accordance with the PRISMA guidelines and an assessment of bias were performed. Included studies reported on the risk factors of pneumonia development after HNC treatment via odds ratios and subdistribution hazard ratios from regression analysis.

Results

Fifteen studies were included, comprising 30,962 patients with a mean age of 70 years (range, 19-95 years). Of these, 71.6% are male. The results of our study indicate that the following were independent risk factors contributing to the development of pneumonia: male sex, habitual alcohol consumption, poor oral hygiene before treatment, pretreatment dysphagia, hypopharynx and nasopharynx tumor sites, use of radiotherapy with or without chemotherapy versus surgery alone, addition of chemotherapy to radiotherapy, reirradiation, neck dissection, increased duration of tracheotomy, and use of sedatives for sleeping.

Conclusion

Multiple patient-, tumor-, and treatment-specific risk factors were identified in predicting pneumonia. Recognition of these risk factors early on may help prevent or at least detect pneumonia in this vulnerable group of patients.

Effect of tongue-strengthening exercises on tongue strength and swallowing-related parameters in chronic radiation-associated dysphagia

BACKGROUND

Radiation-associated dysphagia (RAD) is highly prevalent in head and neck cancer (HNC) patients, with insufficient tongue strength (TS) as a characteristic of this disabling complication. The effects of tongue-strengthening exercises (TSE) on TS, swallowing, and quality of life (QoL) have not been studied in this population.

METHODS

A prospective phase 2 study using an 8 weeks during TSE protocol was carried out in 15 patients with chronic RAD. Outcome parameters were maximal isometric pressure (MIP), TS during swallowing (Pswal), swallowing function, and QoL. All parameters were evaluated at baseline, after 4 and 8 weeks of training, and 4 weeks after the last training session.

RESULTS

MIP increased significantly, without detraining effects. Pswal did not increase significantly, but relevant effect sizes were measured. Swallowing function ameliorated, but did not result in increased functional oral intake, self-reported outcome or QoL.

CONCLUSION

TSE in patients with RAD results in increased strength and swallowing function.

Decreased Tongue Volume Post Radiation

OBJECTIVES

To evaluate volume changes within the tongue post chemoradiation therapy (CRT).

STUDY DESIGN

Retrospective review.

SETTING

Academic Medical Center.

SUBJECTS AND METHODS

Subjects included 19 patients that received CRT as the primary treatment for tonsillar or hypopharynx squamous cell carcinoma. Tongue volumes were calculated by three raters from thin slice computed tomography images collected before treatment and up to 29 months post-CRT. Body mass index (BMI) was also collected at each time point.

RESULTS

Inter-rater reliability was high with an ICC of 0.849 (95% CI = 0.773, 0.905). Linear mixed effects modeling showed a mean decrease of 0.45 cm³ (standard error of the mean [SEM] = 0.11) in tongue volume per month post-CRT (P < .001). However, the addition of BMI to the model was significant (χ² (4) = 25.0, P < .001), indicating that BMI was a strong predictor of tongue volume, with a mean decrease of 1.75 cm³ (SEM = 0.49) in tongue volume per unit decrease in BMI (P < .001) and reducing the post-CRT effect on tongue volume decrease per month to 0.23 cm³ (P = .02). BMI significantly (P < .001) decreased by 0.11 units (SEM = 0.02) per month post radiation.

CONCLUSION

Tongue dysfunction and decreased tongue strength are significant contributors to the dysphagia that patients experience after receiving CRT. In this study, both tongue volume and BMI decreased post-CRT; therefore, BMI could potentially be used as a predictor of tongue volume post-CRT.

Larynx-preserving reconstruction after extended base of the tongue resection

BACKGROUND

As the base of the tongue (BOT) plays essential roles in speech and swallowing, surgical resection of BOT cancer is typically avoided. Moreover, standard reconstructive procedures for larynx-preserving BOT defects have not yet been established. We performed immediate flap reconstruction after wide resection of BOT cancer with laryngeal preservation. Herein, the functional and oncological results of our strategy were analysed.

METHODS

We retrospectively evaluated patients who underwent extended BOT resection (including the oral tongue, upper/lateral oropharyngeal wall, epiglottis and false vocal cord) with laryngeal preservation between April 2006 and April 2016. We classified defects involving the oral tongue or upper/lateral oropharyngeal wall as the lateral extension type and those involving the epiglottis or false vocal cord as the laryngeal extension type. Lateral extension-type defects were closed primarily and filled with a deepithelialised skin or muscle flap. Laryngeal extension-type defects were reconstructed using a bulky skin flap plus hyo-thyroid-pexy to create a neo-epiglottis. Postoperative functional and oncologic outcomes were assessed.

RESULTS

We enrolled 18 patients with extended BOT defects. Of them, 11 had a history of irradiation. The tracheal cannula was removed in all cases, although laryngeal extension defects were associated with a longer duration to removal. All patients achieved complete oral intake and retained intelligible speech, with preservation of laryngeal function. There was no local recurrence, and the 5-year overall survival was 88.9%.

CONCLUSIONS

Following wide BOT resection, reconstruction with laryngeal preservation is feasible even in cases involving irradiated tumours with laryngeal extension.

Utilization of rehabilitation services in patients with head and neck cancer in the United States: A SEER-Medicare analysis

BACKGROUND

Head and neck cancer (HNC) and its treatment lead to functional impairments. Rehabilitation by speech-language pathology (SLP) and occupational/physical therapy (OT/PT) can decrease morbidity.

METHODS

The Surveillance, Epidemiology and End Results-Medicare data for patients with HNC diagnosed between 2002 and 2011 was utilized to evaluate posttreatment rehabilitation.

RESULTS

In 16 194 patients, the overall utilization rate was 20.7% for SLP and 26.2% for OT/PT services. Treatment modality was significantly associated rehabilitation utilization. Compared to patients treated with primary surgery, those treated with primary radiotherapy had significantly lower odds of OT/PT utilization. Patients treated with surgery plus adjuvant treatment and primary concurrent chemoradiation had higher odds of SLP utilization compared to patients treated with surgery alone.

CONCLUSIONS

Rehabilitation services appeared to be underutilized by patients with HNC in the United States and vary with treatment modality. There is a need to improve integration of rehabilitation services into the HNC care continuum.

SUMMARY

Rehabilitation services are underutilized by patients with HNC during posttreatment surveillance in the United States. Treatment modality significantly impacts rehabilitation utilization patterns.

Incidence of Long-Term Esophageal Dilation With Various Treatment Approaches in the Older Head and Neck Cancer Population

Purpose: Treatments for locoregionally advanced head and neck cancer (LAHNC) negatively impact swallowing function, but the long-term incidence of severe toxicity requiring esophageal dilation is not well-documented in the population. The aim of this study was to compare the incidence of long-term esophageal dilation across varying treatments for LAHNC.

Methods and Materials: We identified 5,223 patients with LAHNC diagnosed from 2000 to 2009 in the SEER-Medicare database. We compared the incidence of esophageal dilation for surgery alone vs. surgery plus adjuvant radiotherapy (RT) and chemoradiotherapy (CRT) vs. definitive RT or CRT.

Results: The cumulative incidence of esophageal dilation for all sites at 10 years, according to treatment group were as follows: CRT, 14% (95% confidence interval (CI), 12–17%); definitive RT, 13% (95% CI, 10–16%); surgery alone, 5% (95% CI, 3–7%); surgery and CRT, 15% (95% CI, 11–19%); surgery and adjuvant RT: 10% (95% CI, 8–13%). There was no significant difference in the incidence of esophageal dilation between surgery plus adjuvant RT/CRT or definitive RT/CRT (p = 0.37), but the incidence was significantly increased in both groups compared to surgery alone (p = 0.003). On multivariable analysis, chemotherapy was associated with significantly increased incidence of esophageal dilation (HR 2.9, 95% CI 1.5–5.5, p < 0.001) in oropharyngeal cancers.

Conclusions: The incidence of esophageal dilation is similar in LAHNC patients undergoing RT with or without surgery. Chemoradiotherapy increases the long-term risk of esophageal dilation events over surgery alone.

Functional Swallowing Units (FSUs) as organs-at-risk for radiotherapy. PART 1: Physiology and anatomy

BACKGROUND AND PURPOSE

When optimising radiotherapy treatments today, the pharyngeal constrictor muscles and the larynx are usually regarded as the swallowing organs at risk (SWOARs). The purpose of this study was to identify and describe additional, previously undefined groups of muscles (functional units) involved in crucial components of swallowing (hyolaryngeal elevation (HLE), tongue base retraction (TBR) and tongue motion), and to emphasise their relevance in radiation-induced dysphagia.

MATERIAL AND METHODS

Based on available literature on human anatomy and swallowing physiology, the functional units of muscles involved in HLE, TBR and tongue motion have been identified and described.

RESULTS AND CONCLUSION

Functional swallowing units (FSUs) were defined as groups of swallowing muscles sharing their function, that are in close proximity to each other. Seven FSUs involved in HLE, TBR and tongue motion were identified: floor of mouth, thyrohyoid muscles, posterior digastric/stylohyoid muscles complex, longitudinal pharyngeal muscles, hyoglossus/styloglossus muscles complex, genioglossus muscles, intrinsic tongue muscles. The swallowing physiology and anatomy of the FSUs described in this paper will lead to a greater understanding of radiation-induced dysphagia mechanisms and, consequently, to an improvement in the development of swallowing sparing strategies. This article (PART 1) serves as the theoretical foundation for a subsequent article (PART 2), which provides detailed delineation guidelines for FSUs.

Dysphagia Onset in Older Adults during Unrelated Hospital Admission: Quantitative Videofluoroscopic Measures

New-onset swallowing difficulties in older patients during unrelated hospital admissions are well recognized and may result in prolonged hospital stay and increased morbidity. Presbyphagia denotes age-related swallowing changes which do not necessarily result in pathological effects. The trajectory from presbyphagia to dysphagia is not well understood. This retrospective observational study compared quantitative videofluoroscopic measures in hospitalized older adults aged 70-100 years, reporting new dysphagia symptoms during admission (n = 52), to healthy asymptomatic older (n = 56) and younger adults (n = 43). Significant physiological differences seen in hospitalized older adults but not healthy adults, were elevated pharyngeal area (p < 0.001) and pharyngeal constriction ratio (p < 0.001). Significantly increased penetration (p < 0.001), aspiration (p < 0.001) and pharyngeal residue (p < 0.001) were also observed in the hospitalized older cohort. Reasons for onset of new swallow problems during hospitalization are likely multifactorial and complex. Alongside multimorbidity and polypharmacy, a combination of factors during hospitalization, such as fatigue, low levels of alertness, delirium, reduced respiratory support and disuse atrophy, may tip the balance of age-related swallowing adaptations and compensation toward dysfunctional swallowing. To optimize swallowing assessment and management for our aging population, care must be taken not to oversimplify dysphagia complaints as a characteristic of aging.

Analysis of dysphagia in advanced-stage head-and-neck cancer patients: impact on quality of life and development of a preventive swallowing treatment

OBJECTIVES

Swallowing and voice dysfunctions are common side effects following head-and-neck squamous-cell carcinoma (HNSCC) treatment. Our aim was to analyze the relationships between quality of life, swallowing, and phonatory problems in patients with an advanced-stage HNSCC and to prospectively evaluate the effects of a prophylactic swallowing program.

METHODS

First, we retrospectively studied 60 advanced HNSCC patients treated with exclusive or adjuvant radiotherapy/chemoradiotherapy (RT/CRT). Subjects were classified according to general and clinical-therapeutic features. Outcome measures included EORTC QLQ-C30, EORTC QLQ-H&N35, Dysphagia Handicap Index (DHI), M.D.Anderson Dysphagia Inventory (MDADI), and Voice Handicap Index (VHI). Then, we conducted a prospective evaluation of a prophylactic swallowing counselling in 12 consecutive advanced-stage HNSCC patients by a two-arm case-control analysis. These patients were treated with exclusive or adjuvant RT/CRT.

RESULTS

71% of the retrospective population studied reported swallowing dysfunction as a major side effect. No differences were detected in the severity of dysphagia or dysphonia according to type of treatment or staging of the primary tumour, while hypopharyngeal and laryngeal cancer patients showed significantly better swallowing ability and better QoL compared to oral cavity and oropharyngeal localisation (p < 0.05). In addition, a relevant correlation between swallowing and voice problems emerged (p < 0.05). In the prospective part, while no statistical correlation was evident before the start of RT/CRT in the experimental group compared to the control one, the former showed better performances at MDADI (p = 0.006) and DHI (p = 0.002) test 3 months after its end.

CONCLUSION

Dysphagia is both an acute-and-long-term side effect which greatly affects QoL of HNSCC patients undergoing multimodality treatment. Our data show that a prophylactic swallowing program could actually produce a beneficial effect on patients' outcomes.

LEVEL OF EVIDENCE

1b and 2b.

Squamous Cell Carcinoma of the Soft Palate in the United States: A Population-Based Study

Objectives To describe the incidence and determinants of survival of patients with squamous cell carcinoma of the soft palate (SCCSP) using the Surveillance, Epidemiology, and End Results (SEER) database. Study Design Retrospective, population-based cohort study of patients. Setting SEER cancer registry. Subjects and Methods Patients from the SEER cancer registry from 1973 to 2015 were used to analyze demographics and survival of SCCSP. Results A total of 4366 cases were identified. The average overall survival (OS) and disease-specific survival (DSS) were 68.7 months and 161.3 months, respectively. Multivariate analysis revealed that male sex, stage, and treatment (hazard ratio [HR] = 0.690, P = .019; HR = 1.73, P < .001; HR = 0.64, P < .001, respectively) were independent determinants of better or worse DSS. Age, stage, and treatment (HR = 1.02, P < .001; HR = 1.49, P < .001; HR = 0.66, P < .001; HR = 0.48, P < .001, respectively) were independent determinants of better or worse OS. For stages I, II, and III, radiation alone and surgery alone have nearly equivalent OS. Patients with stage IV disease who underwent both surgery and radiation had a significantly higher median OS at 50.0 months. Conclusion Radiation alone and surgery alone both have nearly equivalent OS benefit for stages I to III, while surgery and radiation provide the most survival benefit for stage IV disease. The large discrepancy between OS and DSS can be due to significant comorbidities. Future studies should aim to address the determinants of quality-of-life variables that help direct treatment decisions and might indirectly affect survival.

Dysphagia and Oral Morbidities in Chemoradiation-Treated Head and Neck Cancer Patients

This study prospectively evaluated relationships between oral morbidities and swallowing ability in head/neck cancer patients following chemoradiation therapy (CRT) and at 3 months following CRT. Thirty patients with confirmed head/neck cancer undergoing chemoradiation were assessed with a battery of swallowing measures and measures of oral morbidities related to chemoradiation (xerostomia, mucositis, pain, taste/smell, oral moisture). All measures were completed at baseline (within the first week of CRT), at 6 weeks (end of treatment), and at 3 months following chemoradiation. Descriptive and univariate statistics were used to depict change over time in swallowing and each oral morbidity. Correlation analyses evaluated relationships between swallowing function and oral morbidities at each time point. Most measures demonstrated significant negative change at 6 weeks with incomplete recovery at 3 months. At 6 weeks, mucositis ratings, xerostomia, and retronasal smell intensity demonstrated significant inverse relationships with swallowing function. In addition, oral moisture levels demonstrated significant positive relationships with swallowing function. At 3 months, mucositis ratings maintained a significant, inverse relationship with swallow function. Taste and both orthonasal and retronasal smell intensity ratings demonstrated inverse relationships with measures of swallow function. Swallow functions and oral morbidities deteriorate significantly following CRT with incomplete recovery at 3 months post treatment. Furthermore, different patterns of relationships between swallow function measures and oral morbidities were obtained at the 6-week versus the 3-month assessment point suggesting that different mechanisms may contribute to the development versus the maintenance of dysphagia over the trajectory of treatment in these patients.

A review of diet standardization and bolus rheology in the management of dysphagia

PURPOSE OF REVIEW

Texture modification is a widespread practice as a strategy for the management of dysphagia and can be very effective in individual cases. However, it is often performed in a qualitative, subjective manner and practices vary internationally according to multiple sets of national guidelines. This article aims to identify best practice by reviewing the theory and practice of texture modification, focussing on recent advances.

RECENT FINDINGS

Instrumental assessment of texture modification in vivo is challenging, and studies including rheology and perception have indicated that fluid viscosity is only one of many factors affecting texture modification in practice. Systematic reviews have identified a historical lack of high-quality clinical evidence, but recent controlled studies are beginning to identify positive and negative aspects of thickened fluids. Research and practice to date have been limited by the lack of control and standardization of foods and drinks. However in 2015 a not-for-profit organization, the International Dysphagia Diet Standardisation Initiative, has published a framework for texture modification from thin liquids to solid foods based on all the existing documentation and guidance, and the - limited - available clinical evidence.

SUMMARY

Rheology exists in the lab; however, normal practice is often subjective or lacking control and standardization. In the near future, cohesion of practice and the availability of practical standardization tools may increase awareness and use of rheology.

Persistent Tracheostomy after Organ Preservation Protocol in Patients Treated for Larynx and Hypopharynx Cancer

Introduction  Squamous cell carcinoma of the larynx is currently the second most common malignancy of the airway after lung cancer, and hypopharyngeal cancer accounts for fewer than 5% of head and neck cancers. The nonsurgical options for patients with this disease are related to significant long-term toxicities and the need for persistent tracheostomy, which adversely affects the quality of life of these patients. Objective  To evaluate the need for tracheostomy, and the influence of this in the overall and specific survival rates of patients diagnosed with all stages of laryngeal carcinoma treated by chemoradiotherapy. Methods  A retrospective study of patients diagnosed with laryngeal carcinoma was performed according to the criteria of the Union for International Cancer Control (UICC) and the American Joint Committee on Cancer (AJCC) 7th edition, in a tertiary hospital. Results  A total of 21 patients were evaluated, 8 patients required a tracheotomy (31%) during the treatment protocol, 7 (35%) men and 1 (100%) women. According to subsite 4/4 patient with glottis cancer (p ≤ 0.001), 2/10 patients with supra glottis cancer and 2/7 patients with hypopharyngeal cancer. During follow up, just in 1 patient was possible to close the tracheostomy. Conclusion  Persistent tracheostomy dependence after primary chemoradiation increases significantly the morbidity, and decreases the quality of life of those patients. Patients with glottis cancer are prone to need a tracheostomy, but no statistical difference regarding the oncological stage and the need for a tracheostomy were detected. A more thorough selection of the patients is needed to improve the quality of life and reduce permanent tracheostomy dependence.

Predictors of Aspiration Pneumonia following Radiotherapy for Head and Neck Cancer

Objectives

Aspiration following radiotherapy for head and neck cancer (HNC) is a common event, but not all patients with aspiration will develop pneumonia. Our aim was to identify predictors of pneumonia in patients with aspiration following radiotherapy for HNC.

Methods

We performed a retrospective study of 52 patients referred for modified videofluoroscopic barium swallow (MVBS) testing at our institution from 2003 to 2007 in order to identify clinical variables associated with the diagnosis of aspiration pneumonia.

Results

Independent risk factors for the development of pneumonia were tracheobronchial aspiration on MVBS testing (odds ratio [OR], 5.0; 95% confidence interval [CI], 1.2 to 20.5; p = 0.025), malnutrition (OR, 4.4; 95% CI, 1.3 to 14.7; p = 0.018), and smoking history (OR, 1.04 per pack-year; 95% CI, 1.01 to 1.07; p = 0.011). Through logistic regression analysis, we developed a bivariate predictive model with a sensitivity of 58%, a specificity of 90%, a positive predictive value of 79%, and a negative predictive value of 77% for the development of aspiration pneumonia in our patient population.

Conclusions

Depth of aspiration on MVBS testing, malnutrition, and smoking history were strongly associated with the development of aspiration pneumonia in our patient population. The use of clinical variables to determine the risk of aspiration pneumonia is feasible and may help identify high-risk patients.

Soft Electronics Enabled Ergonomic Human-Computer Interaction for Swallowing Training

We introduce a skin-friendly electronic system that enables human-computer interaction (HCI) for swallowing training in dysphagia rehabilitation. For an ergonomic HCI, we utilize a soft, highly compliant ("skin-like") electrode, which addresses critical issues of an existing rigid and planar electrode combined with a problematic conductive electrolyte and adhesive pad. The skin-like electrode offers a highly conformal, user-comfortable interaction with the skin for long-term wearable, high-fidelity recording of swallowing electromyograms on the chin. Mechanics modeling and experimental quantification captures the ultra-elastic mechanical characteristics of an open mesh microstructured sensor, conjugated with an elastomeric membrane. Systematic in vivo studies investigate the functionality of the soft electronics for HCI-enabled swallowing training, which includes the application of a biofeedback system to detect swallowing behavior. The collection of results demonstrates clinical feasibility of the ergonomic electronics in HCI-driven rehabilitation for patients with swallowing disorders.

Guidelines for the Surgical Management of Laryngeal Cancer: Korean Society of Thyroid-Head and Neck Surgery

Korean Society of Thyroid-Head and Neck Surgery appointed a Task Force to develop clinical practice guidelines for the surgical treatment of laryngeal cancer. This Task Force conducted a systematic search of the EMBASE, MEDLINE, Cochrane Library, and KoreaMed databases to identify relevant articles, using search terms selected according to the key questions. Evidence-based recommendations were then created on the basis of these articles. An external expert review and Delphi questionnaire were applied to reach consensus regarding the recommendations. The resulting guidelines focus on the surgical treatment of laryngeal cancer with the assumption that surgery is the selected treatment modality after a multidisciplinary discussion in any context. These guidelines do not, therefore, address non-surgical treatment such as radiation therapy or chemotherapy. The committee developed 62 evidence-based recommendations in 32 categories intended to assist clinicians during management of patients with laryngeal cancer and patients with laryngeal cancer, and counselors and health policy-makers.

Predicting feeding tube and tracheotomy dependence in laryngeal cancer patients

CONCLUSIONS

The two scales reliably measure laryngeal edema and dysfunction in laryngeal cancer patients. The eight categories from these scales, and abnormal pharyngeal squeeze, can be used to form a new rating scale intended to help clinicians identify and circumvent swallowing complications after chemo-irradiation.

OBJECTIVES

The objectives were to compare two laryngeal edema rating scales in laryngeal cancer patients and determine if post-radiation +/- chemotherapy edema predicts dependence on a feeding tube and/or tracheostomy.

METHODS

A retrospective chart review between 2005-2008 revealed 28 laryngeal cancer patients status post-radiation +/- chemotherapy, with video laryngoscopies performed within 6 months after treatment. Four raters evaluated videos based on the Laryngopharyngeal Edema Scale (LES) and the Reflux Finding Score (RFS). Tracheostomy and feeding tube outcomes were then correlated with the two scales.

RESULTS

Feeding tube and tracheostomy dependence were associated with pre-treatment vocal cord paralysis, advanced T stage, and chemoradiation. Eight categories from the LES and RFS scales were significantly associated with the need for a feeding tube.

The Temporalis Muscle Flap for Palate Reconstruction: Case Series and Review of the Literature

Introduction  The temporalis myofascial (TM) is an important reconstructive flap in palate reconstruction. Past studies have shown the temporalis myofascial flap to be safe as well as effective. Free flap reconstruction of palate defects is also a popular method used by contemporary surgeons. We aim to reaffirm the temporalis myofascial flap as a viable alternative to free flaps for palate reconstruction.

Objective  We report our results using the temporalis flap for palate reconstruction in one of the largest case series reported. Our literature review is the first to describe complication rates of palate reconstruction using the TM flap.

Methods  Retrospective chart review and review of the literature.

Results  Fifteen patients underwent palate reconstruction with the TM flap. There were no cases of facial nerve injury. Five (33%) of these patients underwent secondary cranioplasty to address temporal hollowing after the TM flap. Three out of fifteen (20%) had flap related complications. Fourteen (93%) of the palate defects were successfully reconstructed, with the remaining case pending a secondary procedure to close the defect. Ultimately, all of the flaps (100%) survived.

Conclusion  The TM flap is a viable method of palate defect closure with a high defect closure rate and flap survival rate. TM flaps are versatile in repairing palate defects of all sizes, in all regions of the palate. Cosmetic deformity created from TM flap harvest may be addressed using cranioplasty implant placement, either primarily or during a second stage procedure.

Change of Swallowing in Patients With Head and Neck Cancer After Concurrent Chemoradiotherapy

OBJECTIVE

To evaluate the functional characteristics of swallowing and to analyze the parameters of dysphagia in head and neck cancer patients after concurrent chemoradiotherapy (CCRT).

METHODS

The medical records of 32 patients with head and neck cancer who were referred for a videofluoroscopic swallowing study from January 2012 to May 2015 were retrospectively reviewed. The patients were allocated by duration after starting CCRT into early phase (<1 month after radiation therapy) and late phase (>1 month after radiation therapy) groups. We measured the modified penetration aspiration scale (MPAS) and American Speech-Language-Hearing Association National Outcome Measurement System swallowing scale (ASHA-NOMS). The oral transit time (OTT), pharyngeal delay time (PDT), and pharyngeal transit time (PTT) were recorded to assess the swallowing physiology.

RESULTS

Among 32 cases, 18 cases (56%) were of the early phase. In both groups, the most common tumor site was the hypopharynx (43.75%) with a histologic type of squamous cell carcinoma (75%). PTT was significantly longer in the late phase (p=0.03). With all types of boluses, except for soup, both phases showed a statistically significant difference in MPAS results. The mean ASHA-NOMS level for the early phase was 5.83±0.78 and that for the late phase was 3.79±1.80, with statistical significance (p=0.01). The PTT and ASHA-NOMS level showed a statistically significant correlation (correlation coefficient=-0.52, p=0.02). However, it showed no relationship with the MPAS results.

CONCLUSION

The results of our study suggest that in the late phase that after CCRT, the OTT, PDT, and PTT were longer than in the early phase and the PTT prolongation was statistically significant. Therefore, swallowing therapy targeting the pharyngeal phase is recommended after CCRT.

Benefit of percutaneous endoscopic gastrostomy in patients undergoing definitive chemoradiotherapy for locally advanced nasopharyngeal carcinoma

BACKGROUND AND AIM

To evaluate the impact of percutaneous endoscopic gastrostomy (PEG) tube on nutritional status, treatment-related toxicity, and treatment tolerance in patients with locally advanced nasopharyngeal carcinoma (NPC) who underwent chemoradiotherapy.

PATIENTS AND METHODS

We enrolled 133 consecutive non-metastatic NPC (III/IV stage) patients, who were treated with prophylactic PEG feeding before the initiation of concurrent chemoradiotherapy (CCRT) between June 1, 2010 and June 30, 2014. Meanwhile, another 133 non-PEG patients, who were matched for age, gender, and tumor, node, metastases stage, were selected as historical control cohort. Weight and nutritional status changes from pre-radiotherapy to the end of radiotherapy were evaluated, and treatment tolerance and related acute toxicities were analyzed as well.

RESULTS

We found that significantly more patients (91.73%) in the PEG group could finish two cycles of CCRT, when compared with those in the non-PEG group (57.89%) (P<0.001). We also indicated that more patients (50.38%) in the non-PEG group experienced weight loss of ≥5%, while the phenomenon was only found in 36.09% patients in the PEG group (P=0.019). In addition, the percentage of patients who lost ≥10% of their weight was similar in these two groups. Changes in albumin and prealbumin levels during radiotherapy in the non-PEG group were higher than those obtained for the PEG group with significant differences (P-values of 0.023 and <0.001, respectively). Furthermore, patients in the PEG group had significantly lower incidence of grade III acute mucositis than those in the non-PEG group (22.56% vs 36.84%, P=0.011). Tube-related complications occurred only in 14 (10.53%) patients in the PEG group, including incision infection of various degrees.

CONCLUSION

PEG and intensive nutrition support may help to minimize body weight loss, maintain nutritional status, and offer better treatment tolerance for patients with locally advanced NPC who underwent CCRT.

Videofluoroscopic Swallow Examination Does Not Accurately Detect Cricopharyngeal Radiation Strictures

Videofluoroscopy is the standard technique to evaluate dysphagia following radiotherapy for head and neck cancer (HNC). The accuracy of radiography in detecting strictures at the pharyngoesophageal junction is unknown. Our aim was to determine the diagnostic accuracy of videofluoroscopy in detecting strictures at the pharyngoesophageal junction prior to endoscopic dilatation in a consecutive series of HNC survivors with dysphagia. Presence of a stricture on videofluoroscopy was determined by 3 experienced blinded investigators and compared against a gold standard, defined as presence of a mucosal tear during endoscopic dilatation. In 10 of 33 patients, there was complete agreement among observers with respect to the presence or absence of a stricture. Overall, the concordance among observers in identification of strictures was very poor, with a kappa of 0.05 ( P = .30). The diagnostic sensitivity and specificity of videofluoroscopy in detecting strictures was 0.76 and 0.58, respectively. Videofluoroscopy alone is inadequate to detect strictures in HNC survivors with dysphagia.

New and safe experimental model of radiation-induced neurovascular histological changes for microsurgical research

The aim is to create a new and safe experimental model of radiation-induced neurovascular histological changes with reduced morbidity and mortality for use with experimental microsurgical techniques. Seventy-two Sprague-Dawley rats (250-300 g) were divided as follows: Group I: control group, 24 rats clinically evaluated during six weeks; Group II: evaluation of acute side-effects (two-week follow-up period), 24 irradiated (20 Gy) rats; and Group III: evaluation of subacute side-effects (six-week follow-up period), 24 irradiated (20 Gy) rats. Variables included clinical assessments, weight, vascular permeability (arterial and venous), mortality and histological studies. No significant differences were observed between groups with respect to the variables studied. Significant differences were observed between groups I vs II-III regarding survival rates and histological changes to arteries, veins and nerves. Rat body weights showed progressive increases in all groups, and the mortality rate of the present model is 10.4% compared with 30-40% in the previous models. In conclusion, the designed model induces selective changes by radiotherapy in the neurovascular bundle without histological changes affecting the surrounding tissues. This model allows therapeutic experimental studies to be conducted, including the viability of microvascular and microneural sutures post radiotherapy in the cervical neurovascular bundle.

Pathophysiology of Radiation-Induced Dysphagia in Head and Neck Cancer

Oncologic treatments, such as curative radiotherapy and chemoradiation, for head and neck cancer can cause long-term swallowing impairments (dysphagia) that negatively impact quality of life. Radiation-induced dysphagia comprised a broad spectrum of structural, mechanical, and neurologic deficits. An understanding of the biomolecular effects of radiation on the time course of wound healing and underlying morphological tissue responses that precede radiation damage will improve options available for dysphagia treatment. The goal of this review is to discuss the pathophysiology of radiation-induced injury and elucidate areas that need further exploration.

Internal Lymphedema Correlates with Subjective and Objective Measures of Dysphagia in Head and Neck Cancer Patients

BACKGROUND

Tumor/treatment-related internal lymphedema (IL) and/or external lymphedema (EL) are associated with functional deficits and increased symptom burden in head and neck cancer patients (HNCP). Previously, we noted association between EL/IL and patient-reported dysphagia using the Vanderbilt Head and Neck Symptom Survey (VHNSS) version 1.0.

OBJECTIVE

To determine the relationship between IL/EL and subjective and objective measures of swallowing function.

METHODS

Eighty-one HNCP completed: (1) VHNSS version 2.0, including 13 swallowing/nutrition-related questions grouped into three clusters: swallow solids (ss), swallow liquids (sl), and nutrition(nt); (2) physical assessment of EL using Foldi scale; (3) endoscopic assessment of IL using Patterson scale (n = 56); and (4) modified barium swallow study rated by dysphagia outcome and severity scale (DOSS) and in conjunction with a swallow evaluation by National Outcomes Measurement System (NOMS). Examinations were performed at varied time points to assess lymphedema spectrum, from baseline (n = 15, 18.1%) to 18 months post-therapy (n = 20, 24.1%).

RESULTS

VHNSS swallow/nutrition items scores correlated with NOMS/DOSS ratings (p < 0.001). Highest correlation was with NOMS: ss (-0.73); sl (-0.61); nt (-0.56). VHNSS swallow/nutrition scores correlated with maximum grade of swelling for any single structure on Patterson scale: ss (0.43; p = 0.001); sl (0.38; p = 0.004); nt (0.41; p = 0.002). IL of aryepiglottic/pharyngoepiglottic folds, epiglottis, and pyriform sinus were most strongly correlated with VHNSS and NOMS ratings. NOMS/DOSS ratings correlated with EL (> = -0.34; p < 0.01). No meaningful correlations exist between VHNSS swallow/nutrition items and EL (< ± 0.15, p > 0.20).

CONCLUSIONS

IL correlated with subjective and objective measures of swallow dysfunction. Longitudinal analysis of trajectory and impact of IL/EL on dysphagia is ongoing.

Functional Outcomes Following Chemoradiotherapy for Head and Neck Cancer

OBJECTIVE: To study functional outcomes following concurrent chemoradiotherapy of head and neck cancer.

METHODS: A retrospective chart review assessed diet, feeding tube use, and tracheotomy pretreatment and 3, 6, 12, and 24 months posttreatment.

RESULTS: Of 196 patients who underwent chemoradiotherapy between 1990 and 2002, 148 (76%) required feeding tubes immediately posttreatment; 150 (77%) required nutritional support at 3 months. By 12 months, 92% were tube-free and 83% resumed near-normal diet. Of 17 patients (9%) with tracheotomy posttreatment, 71% were decannulated by 6 months. Stage IV disease strongly predicted prolonged feeding tube use and slow recovery of diet; age ≥60 also predicted slow recovery. Primary site, gender, and radiotherapy schedule did not predict functional recovery after adjusting for stage and age.

CONCLUSION: Few patients required tracheotomy before or during chemoradiotherapy. Many patients required feeding tubes and nutritional support for several months following therapy, but most were tube-free and eating near-normal diets within 1 year. EBM rating: C.

Comparison of swallowing function after intensity-modulated radiation therapy and conventional radiotherapy for head and neck cancer

BACKGROUND

Intensity-modulated radiotherapy (IMRT) is hoped to protect structures important for swallow function. We compared posttreatment swallow function in 7 pairs of patients with head and neck cancer treated with either IMRT or conventional radiotherapy (RT).

METHODS

Patients were matched on tumor characteristics. Swallowing function was evaluated with the modified barium swallow procedure pretreatment and at 3 and 6 months postcancer treatment completion. Swallows were analyzed for bolus transit times, bolus residues, laryngeal closure (LAC) duration, cricopharyngeal opening (CPO) duration, and oropharyngeal swallow efficiency (OPSE). Data were analyzed using multifactor repeated measures analysis of variance and adjusted for baseline function.

RESULTS

Main effect of radiation type was significant for all measures on at least 1 bolus type. Patients treated with IMRT demonstrated shorter bolus transit times, less oral and pharyngeal residue, longer LAC, and larger OPSE.

CONCLUSION

Patients treated with IMRT demonstrated faster, more efficient swallows, and greater airway protection.

Quality of life after different oncologic interventions in head and neck cancer patients

Patient reported outcomes following head and neck cancer are of great importance, given the functional, psychological, and social impacts of the disease and its treatment. In addition, not only is the number of publications on health-related quality of life (HRQOL) increasing in a variety of specialties, but there is also a growing awareness of the potential role of HRQOL in practice. Therefore, we aimed to investigate the HRQOL of head and neck cancer patients following different oncologic interventions, using an internationally established test. In this cross-sectional study, we included three different groups of 32 patients each. Participants had histologically confirmed invasive oral squamous cell carcinoma (OSCC) in the anterior floor of the mouth. Group allocation was based on treatment modality, as follows: only surgery (group 1), operation and adjuvant radiotherapy (XRT) (group 2), and the additional presence of osteoradionecrosis (ORN) (group 3). All patients were questioned about their HRQOL, using the standardized University of Washington Quality of Life Questionnaire (UW-QOL). Surveys for groups 1 and 2 were conducted at least 24 months after the end of tumor-related treatment, in cases of ORN (group 3) 12 months after completion of disease-related treatment. A total of 96 patients were included into this study. The mean age was 62.79 ± 8.93 years. The patients in groups 1 and 2 revealed a reduced quality of life, of a greater magnitude after radiation therapy. Patients felt that radiotherapy was much worse than surgery; however, half of the patients stated that they would repeat radiation therapy if necessary. The subjective evaluation of the HRQOL after surgery and radiotherapy was a valuable instrument for assessing the rehabilitation of patients in the context of their function and quality of life. Radiation therapy can be considered a trigger of functional limitations and emotional distress that contributes to decreased HRQOL in patients with head and neck cancer.