Management of oropharyngeal Dysphagia in laryngeal and hypopharyngeal cancer

Oropharyngeal dysphagia impact of pneumonia risk in neurological patients receiving enteral tube feeding: Insights from a gastroenterologist

BACKGROUND

Oropharyngeal dysphagia is prevalent among neurological patients, often necessitating enteral tube feeding with a nasogastric tube (NGT) or percutaneous endoscopic gastrostomy (PEG). These patients are at significant risk of developing aspiration pneumonia. This study aimed to assess the impact of oropharyngeal dysphagia on pneumonia risk requiring hospitalization in neurological patients on long-term enteral tube feeding.

METHODS

This retrospective observational study was conducted between 2015 and 2022. It included neurological patients who underwent upper gastrointestinal endoscopy combined with a Modified Flexible Endoscopic Evaluation of Swallowing (mFEES) for suspect dysphagia, characterized by difficulty or discomfort in swallowing. Participants were either orally fed or had been on long-term enteral tube feeding via NGT or PEG. A 2-year follow-up was conducted to monitor pneumonia cases requiring hospitalization. Multivariate analyses were conducted to identify risk factors for pneumonia requiring hospitalization.

KEY RESULTS

A total of 226 orally fed and 152 enteral tube-fed patients were enrolled. Multivariate analyses showed a significantly increased risk of pneumonia in patients with a history of pneumonia and those receiving enteral tube feeding. Subgroup analysis indicated a significantly lower risk of pneumonia among enteral tube-fed patients with oropharyngeal dysphagia who PEG-fed patients compared to NGT-fed patients (adjusted HR: 0.21, 95% CI: 0.10-0.44, p < 0.001). The cumulative incidence of pneumonia requiring hospitalization was significantly lower in the PEG group than in the NGT group (p < 0.001).

CONCLUSION

mFEES could be a screening tool for oropharyngeal dysphagia. PEG is preferred over NGT for long-term enteral feeding, as it significantly reduces the risk of pneumonia requiring hospitalization, especially in patients with oropharyngeal dysphagia.

Swallowing Function After Treatment of Laryngeal Cancer

Dysphagia is a common functional outcome following treatment of laryngeal cancer. Despite curative advances in both nonsurgical and surgical approaches, preserving and optimizing swallowing function is critical. Understanding the nature and severity of dysphagia depending on initial tumor staging and treatment modality and intensity is crucial. This chapter explores current evidence on the acute and chronic impacts of treatments for laryngeal cancer on swallow function, as well as the medical and nonmedical management of dysphagia in this population.

Risk Factors for Functional Outcomes in Advanced Laryngeal Squamous Cell Carcinoma

OBJECTIVE

Chemoradiation for patients with laryngeal squamous cell carcinoma (SCC) may achieve organ preservation, but appropriate patient selection remains unknown. This study investigates pre-treatment risk factors associated with functional and survival outcomes after radiation-based therapy in patients with advanced laryngeal SCC.

METHODS

A retrospective cohort study was performed on 75 adult patients with stage III or IV laryngeal SCC receiving definitive radiation-based therapy from 1997 to 2016 at a tertiary care center. Tracheostomy and gastrostomy dependence were the primary functional outcomes. Multivariable logistic regressions were performed to evaluate relationships between pre-treatment factors and tracheostomy and gastrostomy dependence. Time-to-event analyses were performed to determine risk factors associated with overall survival.

RESULTS

Among 75 patients included in the analysis, 30 (40%) patients were tracheostomy dependent and 31 (41%) were gastrostomy tube dependent. The median length of follow-up was 31 months (range = 1 to 142 months). Pre-treatment tracheostomy was a significant predictor of post-treatment tracheostomy (aOR = 13.9, 95% CI = 3.35 to 57.5) and moderate-severe comorbidity was a significant predictor of post-treatment gastrostomy dependence (aOR = 2.96, 95% CI = 1.04 to 8.43). The five-year overall survival was 51% (95% CI = 38 to 64%). Pre-treatment gastrostomy tube dependence was associated with an increased risk of death (aHR = 2.45, 95% CI = 1.09 to 5.53).

CONCLUSIONS

Baseline laryngeal functional status and overall health in advanced laryngeal SCC are associated with poor functional outcomes after radiation-based therapy, highlighting the importance of patient selection when deciding between surgical and non-surgical treatment plans. Laryngoscope, 133:594-600, 2023.

Evaluation of Oropharyngeal Dysphagia in Older Patients for Risk Stratification of Pneumonia

Objective

Nasogastric tube (NGT) and percutaneous endoscopic gastrostomy (PEG) are widely used techniques to feed older patients with oropharyngeal dysphagia. Aspiration pneumonia is the most common cause of death in these patients. This study aimed to evaluate the role of oropharyngeal dysphagia in older patients on long-term enteral feeding for risk stratification of pneumonia requiring hospitalization.

Methods

We performed modified flexible endoscopic evaluation of swallowing to evaluate oropharyngeal dysphagia in older patients and conducted prospective follow-up for pneumonia requiring hospitalization. A total of 664 oral-feeding patients and 155 tube-feeding patients were enrolled. Multivariate Cox analysis was performed to identify risk factors of pneumonia requiring hospitalization.

Results

Multivariate analyses showed that the risk of pneumonia requiring hospitalization significantly increased in older patients and in patients with neurological disorders, tube feeding, and oropharyngeal dysphagia. Subgroup analysis revealed that the risk of pneumonia requiring hospitalization was significantly lower in patients with PEG than in those with NGT among the patients with oropharyngeal dysphagia (adjusted hazard ratio 0.26, 95% confidence interval: 0.11–0.63, P = 0.003).

Conclusions

For older patients with oropharyngeal dysphagia requiring long-term enteral tube feeding, PEG is a better choice than NGT. Further research is needed to elucidate the role of oropharyngeal dysphagia in enteral feeding in older patients.

Results of pretreatment swallowing evaluation in patients with stage III/IV laryngeal and hypopharyngeal carcinoma

INTRODUCTION

Laryngeal and hypopharyngeal carcinoma are among the common head and neck cancers causing considerable swallowing dysfunction. The functional status of the organ (larynx) is an important point of contention while considering the patients for organ preservation protocol.

METHODOLOGY

The aim of this retrospective study was to assess the swallowing status in stage III/IV laryngeal and hypopharyngeal carcinoma and its influence on treatment decision. We evaluated all treatment naïve patients who were referred to the swallowing clinic in 2017 (Jan-Dec) for assessment of swallowing prior to treatment initiation.

RESULTS

One hundred patients satisfied the eligibility criteria and were included in the study. The site and stage of laryngeal and hypopharyngeal cancer cases were almost equal in number. Their median age was 58 years. Fiberoptic endoscopic evaluation of swallowing (FEES) was done in all patients. 30% of the patients only had swallowing difficulties. Only advanced T-stage (p = 0.04) had an influence on the pretreatment swallowing status. Thirty-seven patients required nasogastric tube (NGT) for feeding. By 2 month post-treatment completion, most patients on NGT could resume oral feeding.

CONCLUSIONS

Pretreatment swallowing assessment alone did not significantly seem to influence our decisions for organ preservation treatment. However, patients with aspiration could be identified and managed appropriately. Most patients on NGT could resume oral feeds post-treatment completion.

Percutaneous Endoscopic Gastrostomy versus Nasogastric Tube Feeding: Oropharyngeal Dysphagia Increases Risk for Pneumonia Requiring Hospital Admission

Background: Aspiration pneumonia is the most common cause of death in patients with percutaneous endoscopic gastrostomy (PEG) and nasogastric tube (NGT) feeding. This study aimed to compare PEG versus NGT feeding regarding the risk of pneumonia, according to the severity of pooling secretions in the pharyngolaryngeal region. Methods: Patients were stratified by endoscopic observation of the pooling secretions in the pharyngolaryngeal region: control group (<25% pooling secretions filling the pyriform sinus), pharyngeal group (25–100% pooling secretions filling the pyriform sinus), and laryngeal group (pooling secretions entering the laryngeal vestibule). Demographic data, swallowing level scale score, and pneumonia requiring hospital admission were recorded. Results: Patients with NGT (n = 97) had a significantly higher incidence of pneumonia (episodes/person-years) than those patients with PEG (n = 130) in the pharyngeal group (3.6 ± 1.0 vs. 2.3 ± 2.1, P < 0.001) and the laryngeal group (3.8 ± 0.5 vs. 2.3 ± 2.2 vs, P < 0.001). The risk of pneumonia was significantly higher in patients with NGT than in patients with PEG (adjusted hazard ratio = 2.85, 95% CI: 1.46–4.98, P < 0.001). Cumulative proportion of pneumonia was significantly higher in patients with NGT than with PEG for patients when combining the two groups (pharyngeal + laryngeal groups) (P = 0.035). Conclusion: PEG is a better choice than NGT feeding due to the decrease in risk of pneumonia requiring hospital admission, particularly in patients with abnormal amounts of pooling secretions accumulation in the pyriform sinus or leak into the laryngeal vestibule.

Plummer-Vinson syndrome: improving outcomes with a multidisciplinary approach

Plummer-Vinson syndrome is a rare condition associated with dysphagia, iron deficiency, and esophageal webs. Data regarding this condition is limited to mostly case reports and a few small cohort studies. Although most cases have a benign and indolent course, the risk of malignancy warrants long-term surveillance. A multidisciplinary approach among healthcare providers is of the utmost importance in the management of this condition.

Early Assessment and Management of Dysphagia After Lung Resection: A Randomized Controlled Trial

BACKGROUND

Aspiration resulting from oropharyngeal dysphagia has been recognized as a serious complication after lung resection. The primary aim of this study was to determine whether early detection of postoperative dysphagia would reduce pneumonia among these patients. The median length of hospital stay was assessed.

METHODS

In this single-center, randomized controlled trial, the experimental group underwent clinical assessment of dysphagia before the initiation of oral intake after surgery. Therapeutic interventions were implemented immediately for patients diagnosed with dysphagia. The risk of pneumonia and the median length of hospital stay were compared between the 2 groups.

RESULTS

Between February 2014 and May 2016, 438 patients were randomized. Complete data from all randomized patients were analyzed. Eight cases out of 219 (3.7%) with postoperative dysphagia were detected in the experimental group. Pneumonia occurred in 14 cases out of 219 (6.4 %) in the experimental group and in 27 cases out of 219 (12.3 %) in the control group. The resulting risk reduction for pneumonia was 5.9% in the experimental group (95% confidence interval, 0.44-11.56; P = .033). The median length of hospital stay was 6 (5-8 [25th-75th percentile]) days in the experimental group and 7 (5-10 [25th-75th percentile]) days in the control group (P = .083).

CONCLUSIONS

Early detection of postoperative dysphagia can significantly decrease the risk of postoperative pneumonia in patients undergoing lung resection.

Evaluation of Oropharyngeal Dysphagia in Patients Who Underwent Percutaneous Endoscopic Gastrostomy: Stratification Risk of Pneumonia

BACKGROUND

Aspiration pneumonia is the most common cause of death in patients who undergo percutaneous endoscopic gastrostomy (PEG). This study aims to evaluate the severity of oropharyngeal dysphagia and predict the risk of pneumonia in such patients, using upper gastrointestinal endoscopy.

METHODS

Endoscope examined the pharyngolaryngeal region in patients who underwent PEG. The severity of oropharyngeal dysphagia was evaluated according to the amount and location of pooling of secretions in the pharyngolaryngeal region. Overall, 55 patients showed absent or minimal amount of secretions (control group), 10 patients showed moderate-to-large amounts of secretions filling the pyriform sinus (pharyngeal group), and 23 patients showed secretions entering the laryngeal vestibule (laryngeal group). Demographic data, swallowing level scale, and occurrence of pneumonia were recorded.

RESULTS

The incidence of pneumonia was the highest in the pharyngeal group (70.0%), followed by that in the laryngeal (60.9%) and control groups (30.9%; P = 0.010). Multivariable regression showed that risk of pneumonia was significantly higher in the pharyngeal and laryngeal groups. Cumulative incidence rate of pneumonia was significantly higher in the laryngeal and pharyngeal groups than in the control group (log-rank test, P = 0.001). Mortality rate was significantly higher in patients with suboptimal protective cough reflex than in others (50.0% vs 5.9%, P = 0.034).

CONCLUSION

Accumulation of abnormal amounts of secretions in the pyriform sinus or in the laryngeal vestibule increased the risk of the hospital admission following pneumonia in patients who underwent PEG. The mortality rate was higher in patients with suboptimal protective cough reflex.

Method for dealing with severe aspiration using a new concept of intralaryngeal prosthesis: A case report

BACKGROUND

Deglutition disorders are frequent in patients treated for cancer of the oropharynx, and are responsible for severe aspiration and, in some cases, may require the use of enteral nutrition by gastrostomy or tracheotomy.

METHODS

We present the case of a patient with a medical history of infiltrating laryngeal carcinoma treated by partial laryngectomy and radiochemotherapy, presenting severe aspiration causing significant weight loss. The patient received a new intralaryngeal prosthesis to prevent aspiration with the objective of regaining safe oral nutrition and closure of the tracheotomy.

RESULTS

Deglutition tests after postimplantation demonstrated significantly improved airway protection and recovery deglutition, allowing the patient to return home with resumption of varied solid and a liquid diet.

CONCLUSION

For a patient presenting severe aspiration, the intralaryngeal prosthesis allowed a resumption of oral feeding without exclusion of the larynx or airway protection by tracheotomy. © 2016 Wiley Periodicals, Inc. Head Neck 38: First-E2507, 2016.

Compensatory Mechanisms in Patients After a Partial or Total Glossectomy due to Oral Cancer

Excision of a part or the whole of tongue due to oral cancer disturbs swallowing and speech. Lower airways aspiration of the swallowed bolus in patients after such oral structures excision is a symptom of major swallowing disorder and may be the cause of aspiration pneumonia. Restoration of oral nutrition is possible after exclusion or reduction of aspiration threat in the patients. Video fluoroscopic evaluation of the swallowing performed at the beginning of the swallowing rehabilitation in 95 patients after a total or partial glossectomy due to oral cancer, who assessed their saliva swallowing as efficient on the day of examination, showed disturbances of all of the swallowing stages. The most common disturbances involved the oral stage: limited mobility of the oral tongue, impaired glossopalatal seal, and weak glossopharyngeal seal. The most serious among them involved pharyngeal stage of swallowing, as leakage into the larynx and aspiration. The patients used their own methods during barium suspension swallowing to facilitate the swallowing act. They used such methods as: changing the position of the head to the body, additional swallows, engaging the adjacent structures into sealing the oral fissure. We assumed that the compensatory mechanisms (CM) worked out by the patients before the swallowing examination will enable them efficient barium suspension swallowing. The CM were applied by 71 of 95 patients; 51 of the patients used more than one compensatory mechanism. Swallowing in 61 of the compensating patients was at least functional; swallowing in 10 of the compensating patients was non-efficient and caused recurrent aspiration. The results of our research negate the validity of multiple swallows (more than three) without apnea elongation because it may lead to aspiration. Aspiration was also recorded in patients with weak airways closure and immovable epiglottis, who complemented the impaired oral transport with gravitational oral transport by moving chin up during a swallow. The hypothesis that CM applied by the patients after oral cancer excision during saliva swallowing will be helpful in swallowing of the barium suspension was not proved. In 10 of all the patients recurring aspiration was found despite CM application. Determination of aspiration risk is the key to efficient swallowing rehabilitation. The assessment of CM applied spontaneously by the patients' maintenance validity is particularly important. Video fluoroscopic examination of swallowing allows to assess the aforementioned issue and is crucial for better comprehension of CM applied by the patients in creating a new swallowing pattern after oral cancer excision.