Head and neck cancer
Head and neck cancer and the treatments associated with this diagnosis have a long and well-established relationship with dysphagia. In very advanced cancer diagnoses, especially in cases where previous treatments have failed or resulted in severe complications, the need for a complete removal of the larynx may become necessary. An understanding of swallowing in this subset of head and neck cancer patients – the total laryngectomized population, is not as well understood. It is clear that in the total laryngectomy (TL) surgery, there is a complete and permanent separation of the trachea from the pharynx/esophagus, yielding the structural inability to aspirate. However, actual reports of functional swallowing difficulty and dysphagia in this population are disputed, with incidence ranging in the literature from 17-70% 9. In fact, it was not so long ago that patients in the pre-operative setting were informed, that while communication would drastically be altered, the total laryngectomy surgery would resolve any difficulties with swallowing. While a diet is likely to be safe and many total laryngectomized patients are able to resume PO diets, this does not mean that swallow function is necessarily normalized 2.
Swallowing in the absence of a larynx is anything but normal
In a 2012 study looking at outcomes of individuals post elective total laryngectomy for laryngopharyngeal dysfunction, it was reported that while rates of pneumonia, feeding tube dependence and NPO status significantly decreased, dysphagia symptoms did not fully resolve and in some patients, supplemental tube feedings were an ongoing need 2. A 2008 Australian study found that 71.8% of the participants reported some level of dysphagia and in that cohort; severe distress was reported by 39.7% respondents 9.
Total laryngectomy is a life altering surgery, involving a complete removal of the larynx. There is major disruption to the anatomy and physiology of the swallowing mechanism, not to mention changes to communication and respiratory function. The anatomy and physiology of the newly constructed pharynx or neopharynx can vary depending on the specific type of reconstruction. Regardless of the reconstruction specifics, the muscles and nerves that once supported and innervated the larynx are no longer serving their original purpose, the laryngeal structure is no longer providing an anchor to the tongue and the newly reconstructed esophagus is composed of remaining pharyngeal mucosa and pharyngeal constrictor muscles and/or vascularized tissue brought from a donor site. The interplay of muscular contraction and pressures present in the typical laryngeal swallow is altered dramatically. In this new system, the TL swallow is impacted by changes in sensation, pharyngeal pressures and coordination 10. In addition to what the surgery itself may alter, the immediate and late effects of radiation as a part of an individual’s treatment course can only further impact immediate and long-term swallowing efficiency 3.
Assessment and management
Assessment and management of dysphagia in the total laryngectomy population matters for a number of key reasons, but the biggest reason is quality of life. We no longer want our patients to just be ‘cancer free’. We want them to return to social and work activities and to truly be ‘rehabilitated’. Patients that report dysphagia are more likely to avoid social activities, and have demonstrated significantly higher levels of depression and anxiety 8. Swallowing efficiency can also impact post-laryngectomy voice and voice rehabilitation. This is especially true with tracheoesophageal puncture/prosthesis users. Poor esophageal clearance and efficiency can result in early breakdown of the tracheoesophageal voice prosthesis, reduced voice quality and may place the patient at higher risk of puncture tract enlargement 7.
A clinical assessment looking at cranial nerves and a detailed patient interview are good first steps in the assessment process, however, an instrumental assessment is critical to assess structures and function. There is no data to suggest that one surgical technique over another yields better swallowing outcomes, 10 although the type of reconstruction and treatment course is likely to help guide assessment and management.
Consideration during clinical assessment
- Oral transit time 12
- Dentition/Deglutition 11
- Tongue propulsion and range of motion
- Reduced salivation
- Jaw opening and mobility
Neopharyngeal and Esophageal
- Edema or lymphedema 6
- Structural abnormalities
- UES changes
- Reflux 7
Dysphagia in the total laryngectomy patient is a critical piece to the rehabilitation puzzle that often gets overlooked in this population. More consistent assessment and surveillance of swallowing status can only lead to better care in this challenging and exciting patient population.
- Balfe, D. M., Koehler, R. E., Setzen, M., Weyman, P. J., Baron, R. L., Ogura, J. H. (1982). Barium examination of the esophagus after total laryngectomy. Radiology, 143, 501- 508.
- Hutcheson KA, Alvarez CP, Barringer DA, Kupferman ME, Lapine PR, Lewin JS. Outcomes of elective total laryngectomy for laryngopharyngeal dysfunction in disease-free head and neck cancer survivors. Otolaryngol Head Neck Surg. 2012; 146:585–90.
- Hutcheson KA, Lewin JS, Barringer DA et al. Late dysphagia after radiotherapy-based treatment of head and neck cancer. Cancer 2012; 118(23): 5793-9
- Hutcheson, K. A., Lewin, J. S., Sturgis, E. M. and Risser, J. (2012), Multivariable analysis of risk factors for enlargement of the tracheoesophageal puncture after total laryngectomy. Head Neck, 34: 557–567. doi: 10.1002/hed.21777
- Landera, M. A., Lundy, D. S., & Sullivan, P. A. (2010). Dysphagia after Total Laryngectomy. Perspect Swal Swal Dis (Dysph), 19(2), 39-44. doi: 10.1044/sasd19.2.39.
- Lewin, J. S., Hutcheson, K. A., Barringer, D. A., & Smith, B. G. (2010). Preliminary Experience With Head and Neck Lymphedema and Swallowing Function in Patients Treated for Head and Neck Cancer. Perspect Swal Swal Dis (Dysph), 19(2), 45-52. doi: 10.1044/sasd19.2.45.
- Lorenz, K.J., Grieser,L.,Ehrhart, T. and Maier, H.(2010), Role of Reflux in Tracheoeosphageal Fistula Problems After Laryngectomy. Annals of Otology, Rhinology, & Laryngology. 119(11): 719-728
- Maclean, J., Cotton, S., Perry, A. (2009) Dysphagia Following a Total Laryngectomy: The Effect on Quality of Life, Functioning, and Psychological Well-Being. Dysphagia. 24:314–321
- Maclean, J., Cotton, S., Perry, A.(2009) Post-laryngectomy: It’s hard to swallow. An Australian study of prevalence and self-reports of swallowing function after total laryngectomy. Dysphagia. 24:172–179
- Maclean J, Szczesniak M, Cotton S, Cook I, Perry A.(2011) Impact of a Laryngectomy and Surgical Closure Technique on Swallow Biomechanics and Dysphagia Severity. Otolaryngology-Head and Neck Surgery;144(1)21-28
- Pernambuco LA, Oliveira JHP, Régis RMFL, Lima LM, Araújo AMB, Balata PMM, et al. Quality of life and deglutition after total laryngectomy. Int. Arch. Otorhinolaryngol. 2012;16(4):460-465
- Queija, Débora dos Santos, Portas, Juliana Godoy, Dedivitis, Rogério Aparecido, Lehn, Carlos Neutzling, & Barros, Ana Paula Brandão. (2009). Swallowing and quality of life after total laryngectomy and pharyngolaryngectomy. Brazilian Journal of Otorhinolaryngology, 75(4), 556-564
- Ward EC, et. al. Swallowing outcomes following laryngectomy and total laryngopharyngectomy. Arch Otolaryngol Head Neck Surg. 2002;128:181-186