Dysphagia clinicians working in most medical settings have limited exposure to the head and neck cancer population. This lack of exposure can lead to uncertainty about how to manage these complex patients. Head and neck oncologists often express frustration with the conservative recommendations made by Speech-Language Pathologists (SLPs) and may avoid SLP consultation because of their tendency to recommend NPO status. In this article, I hope to provide important information for clinicians who are new to head and neck dysphagia management to help inform clinical practice standards.
Not the typical dysphagia
Patients with head and neck cancer are a vastly different population than most dysphagic patients referred for SLP care. Whereas a dysphagic patient with a neurological diagnosis is likely to be bed bound and deconditioned, this is not typically the case with head and neck cancer patients. The typical head and neck cancer patient admitted to the hospital is admitted for surgical management from home, where they have typically been active and strong. Thus, functional reserves are characteristically much stronger in the head and neck population than in other populations. This equates to a lower risk and concern for complications from dysphagia such as aspiration pneumonia.
…the SLP must not make recommendations solely based on the swallow study findings, but also must consider the functional/medical repercussions of the dysphagia to date.
If we consider Susan Langmore’s seminal study looking at risk factors for aspiration pneumonia1, two of the factors most associated with development of aspiration pneumonia included dependence for feeding and dependence for oral care. Thus, we see that overall functional/health status and reserve bears a large role in the risk of developing aspiration pneumonia. We can then, be more tolerant of small amounts of aspiration in this population as we expect they will be better able to handle microaspiration than a typical inpatient dysphagic patient. In fact, our head and neck surgical oncology colleagues anticipate some degree of dysphagia and aspiration following surgery and are willing to accept small amounts of aspiration post-operatively for most patients. As SLPs, we are commonly trained to believe that all aspiration must be avoided and it is better to make patients NPO than to allow aspiration. This conservative approach is generally not applicable to the head and neck cancer population. Keeping the swallowing musculature engaged is an important part of post-operative rehabilitation and the SLP caring for head and neck cancer patients after surgery should attempt to maintain some level of PO intake whenever possible.
Though some level of dysphagia is prevalent post-operatively, a recent study of 93,663 patients undergoing head and neck cancer surgery in the US demonstrated an aspiration pneumonia rate of only 2%2. Factors associated with development of aspiration pneumonia during hospitalization in this population included age >80 years, mechanical ventilation, weight loss, and high levels of comorbidity. Thus, we see a picture of increased risk of pneumonia in our oldest, sickest, most deconditioned patients. It is incumbent on the SLP to consider the overall status of the patient in order to assess risk factors when making clinical recommendations. Particular consideration should be given to age, functional reserve, pre-surgical status, and co-morbidities when assessing tolerability of microaspiration. Conservative post-operative management should be reserved for those in these high-risk categories.
In addition to post-operative hospital management of head and neck cancer patients, SLPs are often called upon to provide swallowing care for patients undergoing non-operative therapy. Radiation based therapy (+/- chemotherapy) is increasingly employed due to clinical trials in laryngeal cancer showing oncologic equivalence to total laryngectomy,3-4 as well as the exquisite radiosensitivity of HPV associated oropharyngeal tumors5. Thus, a large proportion of head and neck cancer patients will be treated primarily with radiation/chemoradiation. While these treatment approaches are “organ sparing”, dysphagia remains a common issue after treatment leading to poorer quality of life, health status, and lifespan6-9. Recent evidence has shown that two factors have been associated with better long-term swallowing outcomes; maintenance of oral intake and completion of swallowing exercises during treatment10-12.
The take home message regarding head and neck cancer dysphagia management is that this is a unique patient population which typically presents with lower risk of pulmonary complications such as aspiration pneumonia. As such, SLPs must don a new hat when managing these patients, exchanging conservative management with risk-guided decision making.
While treatment toxicities (pain, taste changes, dry mouth) will undoubtedly impact patient interest in eating during treatment, the SLP must encourage continuation of oral intake during treatment, even when supplemental tube feeds are necessary from a nutrition perspective. The SLP must find consistencies and strategies that will allow the patient to continue oral intake as much as is possible. Avoidance of NPO status is again advised, as discontinuation of muscle engagement will lead to atrophy and greater potential for fibrosis and permanent dysphagia following treatment. Additionally, the SLP must work with the team to find strategies to increase patient adherence to treatment regimens which should include pharyngeal swallowing exercises, tongue strengthening exercises, and jaw mobility exercises. The SLP must maintain an active role with these patients during treatment, particularly those with pre-treatment swallowing dysfunction.
As mentioned previously, acute toxicities of treatment such as taste changes (dysgeusea), dry mouth (xerostomia), and painful swallowing (odynophagia) may negatively influence patient interest in eating and performing swallowing exercises during treatment. Pain in particular can be a great barrier to patients performing swallowing exercises and needs to be addressed in an aggressive and proactive manner. The SLP should work with the treatment team to encourage patients to participate in pain management early before pain becomes unbearable and more challenging to regulate. Radiation based treatment to the head and neck region can be extremely difficult for patients to complete, and the recommendations we make to impact long-term function may seem daunting to our patients. It is essential for the SLP to educate the patient regarding the progressive increase in these symptoms and their expected impact on eating; however, it is equally important to reinforce the importance of continuing muscle engagement through eating and exercising. A compassionate, education-based approach to managing treatment toxicities will yield the greatest potential for patient compliance.
Managing the big picture
The post-radiation dysphagic patient poses a new set of considerations for SLPs and the entire care team. There is growing awareness of a small subset of head and neck cancer patients who develop progressive post-radiation dysphagia (RAD) years following treatment13. Many patients with late RAD will have accommodated to their dysphagia over the years, and due to good functional reserve, they may have limited complications as a result. Swallowing evaluations of these individuals can be striking in regards to physiologic change and its impact on bolus clearance and safety. However, the SLP must not make recommendations solely based on the swallow study findings, but also must consider the functional/medical repercussions of the dysphagia to date. In a patient who is maintaining weight and avoiding pulmonary complications, the SLP should not haphazardly recommend NPO status and PEG placement. Instead, the SLP should have a candid discussion with their patient regarding pneumonia risk and strategies to minimize risk such as compensatory postures/strategies, immaculate oral hygiene, and maintaining an active lifestyle. In the patient who has developed medical complications from their dysphagia, the SLP should engage in a conversation with the patient as well as the rest of the oncology team to assess relative risk as well as patient goals of care.
The take home message regarding head and neck cancer dysphagia management is that this is a unique patient population which typically presents with lower risk of pulmonary complications such as aspiration pneumonia. As such, SLPs must don a new hat when managing these patients, exchanging conservative management with risk-guided decision making. In the head and neck cancer patient with good functional reserve, some tolerance of aspiration is acceptable. The SLP should use their best judgement to determine the safest and most efficient options for head and neck cancer patients and should partner with the oncology team in determining acceptable risk in a case-by-case basis.
- Langmore, SE, Terpenning, MS, Schork, A, Chen, Y, Murray, JT, Lopatin, D, Loesche, WJ. Predictors of aspiration pneumonia: how important is dysphagia? Dysphagia . 1998; 13: 69-81.
- Semenov YR, Starmer HM, Gourin CG. The effect of pneumonia on short-term outcomes and cost of care after head and neck cancer surgery. Laryngoscope 2012; 122(9): 1994-2004.
- Wolf G, Hong K, Fisher S et al. Induction chemotherapy plus radiation compared with surgery plus radiation in patients with advanced laryngeal cancer: The Department of Veterans Affairs Laryngeal Cancer Study Group. N Engl J Med. 1991; 324: 1685-90.
- Forastiere AA, Goepfert H, Maor M, et al. Concurrent chemotherapy and radiotherapy for organ preservation in advanced laryngeal cancer. N Engl J Med. 2003; 349: 2091-8.
- Chen AM, Li J, Beckett LA et al. Differential response rates to irradiation among patients with human papillomavirus positive and negative oropharyngeal cancer. Laryngoscope. 2013; 123(1): 152-7.
- Mowery SE, LoTempio MM, Sadeghi A, et al. Quality of life outcomes in laryngeal and oropharyngeal cancer patients after chemoradiation. Otolaryngol Head Neck Surg, 2006; 135(4):565-70.
- Xu B, Boero IJ, Hwang L, et al. Aspiration pneumonia after concurrent chemoradiotherapy for head and neck cancer. Cancer 2015; 121: 1303-11.
- Forastiere AA, Zhang Q, Weber RS, et al. Long-term results of RTOG 91-11: a comparison of three nonsurgical treatment strategies to preserve the larynx in patients with locally advanced larynx cancer. J Clin Oncol. 2013; 31(7):845-52.
- Starmer HM, Quon H, Simpson M, et al. Speech-language pathology care and short- and long-term outcomes of laryngeal cancer treatment in the elderly. Laryngoscope. 2015; 125(12): 2756-63.
- Carnaby-Mann G, Crary MA, Schmalfus I, Amdur R. “Pharyngocise”: Randomized control trial of preventative exercises to maintain muscle structure and swallowing function during head and neck chemoradiotherapy. Int J Rad Onc Bio Phys 2012; 83: 210-9.
- Langmore S, Krisciunas GP, Miloro KV, et al. Does PEG cause dysphagia in head and neck cancer patients? Dysphagia 2012; 27(2): 251-9.
- Hutcheson KA, Bhayani MK, Beadle BM et al. Eat and exercise during radiotherapy or chemoradiotherapy for pharyngeal cancers. Use it or lose it. JAMA Otolaryngol Head Neck Surg 2013; 139(11):1127-34.
- Awan MJ, Mohamed AS, Lewin JS, et al. Late radiation-associated dysphagia (late RAD) with lower cranial neuropathy after oropharyngeal radiotherapy; a preliminary dosimetric comparison. Oral Oncol. 2014; 50(8): 746-52.