Running head: HEAD AND NECK CANCER

Dysphagia following radiation therapy in head and neck cancer patients

Maria Moritz
University of Wisconsin-Whitewater

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Introduction
Swallowing is a very complex process that requires many systems working together.
Unsurprisingly, treatment for head and neck cancer can disrupt these systems causing dysphagia.
The incidence of long-term dysphagia in head and neck cancer patients is unknown (reports
between 15-100%) and experts believe that dysphagia is under reported in this population
(Langamore & Krisciunas, 2010). Regardless, individuals impacted can have decreased quality
of life, inadequate nutrition, increased incidences of aspiration pneumonia, and increased risk of
death.
Speech language pathologists (SLPs) are critical in the treatment of individuals with head
and neck cancer. SLPs are responsible for assessing swallow function, identifying risk of
aspiration, generating treatment plans, educating patients and caregivers, and working within the
interdisciplinary teams to maximize the patients recovery (Murphy & Gilbert, 2009). It is
important for SLPs to consult the literature to ensure they understand the different types of
cancer treatments available, the physiological changes that cause dysphagia, and how to treat
these individuals to maximize swallow function and quality of life.
Cancer Treatment
Originally, surgery was the main treatment approach for individuals with head and neck
cancer, however, swallowing function was left severely impacted (Lazarus et al., 2000). Surgery
caused tissue loss, damage to muscles and nerves, and a buildup of scar tissue that decreased
sensation in the oral and pharyngeal cavities (Murphy & Gilbert, 2009). After 1990, due to the
impact surgery had on swallowing function, the goal of cancer treatments shifted to an emphasis
on preserving the organs (Langamore & Krisciunas, 2010). The new gold standard for treatment
became radiation therapy. The theory was that preserving the organs anatomy would preserve
the organ function. Unfortunately, radiation therapy can still cause a great deal of physiologic
changes that can impact swallowing function (Lazarus et al., 2000).
Effect of Radiation on Oral and Pharyngeal Phases

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Radiation causes changes and damage to the mucosa and soft tissues within the oral and
pharyngeal cavities (Murphy & Gilbert, 2009). This can lead to problems in both the oral and
pharyngeal phases of swallowing. Complications in the oral phase include reduced lip closure
causing anterior bolus loss; reduced strength in the buccinator muscles causing pocketing;
decreased sensation in the oral cavity causing delayed initiation of the pharyngeal swallow; and
decreased tongue strength and range of motion causing longer oral transit time and residue in the
valleculae and pyriform sinuses prior to the initiation of the swallow ((Murphy & Gilbert, 2009).
According to Lazarus et al. (2000), decreased tongue strength and endurance following
radiation therapy may be a leading contributor of a disordered oral phase. Lazarus et al. (2000)
conducted a study to determine the relationship between tongue strength and endurance and
swallowing function. They compared an experimental group containing 13 patients with
untreated head and neck cancer with a control group containing 13 healthy age and sex-matched
subjects. The experimental group was evaluated both pretreatment and 2-months posttreatment
and the control group was evaluated only once. To test tongue strength and endurance they used
the Iowa Oral Performance Instrument (IOPI) and to test swallowing function they used a
videoflouroscopy. Lazarus et al. (2000) found that tongue endurance was within normal limits
for head and neck cancer patients both pre- and post- radiation. They found that tongue strength
was significantly lower pre- and post- radiation compared to the control group, however, tongue
strength increased from pre- to post- evaluation in the experimental group. Finally, they found
that the experimental group had significantly poorer swallow function than the control group and
that the experimental group had significantly higher incidences of aspiration post- therapy
(Lazarus et al., 2000). Transition
Complications in the pharyngeal phase of the swallow include impaired tongue base to
posterior pharyngeal wall contact, delayed trigger of the pharyngeal swallow, reduced

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pharyngeal muscle constriction, reduced hyolaryngeal excursion, reduced laryngeal vestibule

closer, reduced duration and diameter of the upper esophageal sphincter (UES) opening (Zu,
Yang, and Pelman, 2011), and reduced epiglottis inversion (Murphy and Gilbert, 2009). These
physiological changes lead to inadequate bolus clearance, increased pharyngeal residue, and
increased risk of penetration and aspiration (Murphy & Gilbert, 2009). Many of the disordered
functions in the pharyngeal phase are dependent on the anterior and superior movement of the
hyoid bone during the initiation of the swallow.
According to Zu, Yang, and Pelman (2011), the anterior and superior movement of the
hyoid bone is one of the most critical events for a safe swallow. It is responsible for the
epiglottis inversion, air way closure, and opening the UES. They were interested in how
significantly decreased the hyolaryngeal elevation was after radiation therapy (Zu, Yang, &
Pelman, 2011). They measured the hyoid bone displacement during a swallow in three groups;
individuals with a normal swallow, cancer patients after surgery, and cancer patients after
radiation. The researchers found the post-radiation groups hyolaryngeal excursion was
significantly impaired relative to the normal swallow group. Additionally, the anterior
movement of the hyoid bone was significantly more effected then the superior movement in the
post-radiation group. This means that while the airway is going to remain mostly protected, the
UES is not going to open as wide or as long (Zu, Yang, & Pelman, 2011).
Onset of Dysphagia
The onset of dysphagia in patients with head and neck cancer can occur at different times
during the course of the cancer treatment. Individuals may experience dysphagia before
treatment occurs, immediately after treatment, or several months or years after treatment is
completed (Langamore & Krisciunas, 2010).
When dysphagia is present before treatment occurs it is usually a result of the tumor
disrupting the physiology of the swallow or the pain and discomfort associated with the mass

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(Langamore & Krisciunas, 2010). This dysphagia is eliminated as soon as the tumor is removed.
Dysphagia that presents directly following radiation therapy is considered an acute onset
(Langamore & Krisciunas, 2010). This dysphagia may recover spontaneously within the first
couple of months. It is typically caused by inflammation or pain in the oral and pharyngeal
cavities due to the radiation therapy. As soon the inflammation dissipates and the wounds heal
the dysphagia resolves. This is very common impacting nearly 100% of head and neck cancer
patients and is not cause for concern. Unfortunately, many head and neck cancer patients
experience a more severe form of dysphagia caused by fibrosis (Langamore & Krisciunas, 2010).
In individuals with head and neck cancer, dysphagia can be caused by fibrosis which is a
buildup of scar tissue caused by a disordered healing process: scar tissue continues to build up
even after the wound is fully healed (Langamore & Krisciunas, 2010). Fibrosis causes
stiffening/hardening of the muscles and connective tissues within the aero digestive tract
(Hucheson, 2013). Treatment of fibrosis typically involves flexibility and range of motion
exercises. Fibrosis can cause acute, chronic, and late radiation associated dysphagias which are
differentiated by the time of onset.
Fibrosis presents in the early stages of recovery either during or just after treatment. This
is considered acute dysphagia, also known as a progressive fibrotic onset (Langamore &
Krisciunas, 2010). According to Hutcheson (2013), acute dysphagia occurs within six months of
the completion of radiation. Fibrosis also presents in the later stages of recovery. This is
considered late-effect or chronic dysphagia, also known as spontaneous fibrotic onset.
(Langamore & Krisciunas, 2010). Chronic dysphagia presents between six months and two
years after the completion of radiation therapy (Hutcheson, 2013).
The final type of fibrosis related dysphagia is late radiation associated dysphagia (RAD)
(Hutcheson, 2013). Late RAD is found in individuals who have survived and are free of head
and neck cancer. Most survivors with late RAD have major complications in the pharyngeal

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phase due to decrease laryngeal elevation, epiglottis inversion, tongue base retraction, and
pharyngeal constriction. Stricture (tightening) of the esophagus is present in some cases, but
much less common. Late RAD has only recently emerged in the literature and therefore, the
prevalence is unknown. In a survey of 43 long-term survivors of head and neck cancer, 12%
reported symptoms of dysphagia five years or more after radiation therapy. Due to the high
prevalence and severity of dysphagia in head and neck cancer survivors, it is important to
understand which treatments are most efficacious.
Dysphagia Therapy
Treating dysphagia secondary to head and neck cancer is similar to treating any
dysphagia (Murphy & Gilbert, 2009). The speech language pathologist is expected to provide
compensatory strategies to decrease the risk of aspiration, provide exercises that will increase
swallow function over time, and provide diet recommendations to keep the patient safe and
healthy. The nature of the compensatory strategy, rehabilitation exercise, and diet will depend on
the results of the videoflouroscopic evaluation (Murphy & Gilbert, 2009). There is great
variability among clinicians on the frequency, duration, and intensity of treatment and there are
few clinical studies to help guide best practice (Langamore & Krisciunas, 2010). Some medical
treatments are utilized such as esophageal dilation or vocal fold medialization (Hutcheson,
2013). In extreme cases, elective total laryngectomies (TL) are utilized to prevent aspiration.
Most frequently, these individuals are treated with conventional dysphagia therapies as
symptoms arise. Tongue strengthening exercises are very commonly used because tongue
strength is one of the most frequent complications found in head and neck patients.
Lazarus et al. (2013) decided to see if adding a tongue resistance exercise to conventional
dysphagia treatment would increase swallow function in head and neck cancer patients. The
participants were split into two groups; an experimental group who received the tongue
resistance exercise in addition to conventional therapy and a control group who received the

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conventional therapy in isolation. The researchers measured pre- and post- tongue strength and
oropharyngeal swallow function in both groups. They did not observe any significant
differences in tongue strength or swallow function between the control and experimental groups.
This suggests that adding a tongue strengthening exercise to the treatment protocol is not
beneficial (Lazarus et al., 20013). In addition to the tongue strengthening exercises, the
conventional treatment protocol has not been shown to significantly improve swallow function
when provided post-treatment. It is important for research to find ways to alter or augment the
therapies to make them more efficient (McColloch, Carroll, & Magnuson, 2010). The research
has looked at neuromuscular electrical stimulation (NMES) as a way augment conventional
dysphagia therapy for individuals with head and neck cancer.
In a study by Ryu et al. (2008), NMES was used to target the suprahyoid muscles to
increase laryngeal elevation. They discovered that 90% of speech pathologists who use NMES
use it concurrently with other techniques. They decided the best way to discover if NMES had
any significant effect on swallow function was to compare an experimental group who received
30 minutes of NMES followed by conventional rehabilitative exercises and a control group who
received 30 minutes of a sham stimulation and the same conventional rehabilitative exercises
as the experimental group. The subjects received therapy five days per week for two weeks.
They found that the experimental group made greater gains compared to the control group on
hyolaryngeal elevation and swallow function. This shows the providing NMES alongside
conventional dysphagia therapy may provide the patient with greater and faster benefits. Carroll
et al. (2008) researched another way of altering conventional dysphagia therapy to benefit head
and neck cancer patients.
Carroll et al. (2008) the effects on swallow function when conventional therapy
techniques that are utilized pre-treatment as a preventative therapy. The conventional techniques

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included the tongue hold, tongue resistance, effortful swallow, Mendelsohn maneuver, and
Shaker exercise. Eighteen participants were divided into two groups; the experimental group
who received two weeks of pre-treatment therapy and the control group who received posttreatment therapy. The research found significantly more posterior tongue base retraction and
epiglottis inversion in the experimental (pre-treatment) group. This shows that pre-treatment
therapy can increase swallow function in head and neck cancer patients (Carroll et al., 2008).
According to McColloch, Carroll, and Maguson (2010), in order to obtain maximum gains in
swallow function dysphagia treatment should utilized before, during, and after radiation therapy
(McColloch, Carroll, & Maguson, 2010). Research needs to be conducted in order to determine
the ideal frequency, duration, and intensity of the treatment.
Conclusion
Though there is a great deal of literature regarding cause and treatment of dysphagia in
head and neck cancer after radiation therapy, it does not definitively determine what the best
practice is for patients with dysphagia secondary to head and neck cancer (Langamore and
Krisciunas, 2010). In the research that has surfaced, the sample sizes are small and additional
confounding variables make it difficult to attribute increased swallow function to the directly to
the therapy. Follow-up rate and participant compliance is low in these studies, which can have a
major impact on the results. This is particularly true during research on therapy, due to how
physically limiting radiation therapy can be. Unfortunately, due to the nature of these
confounding variables, conclusive research will continue to be difficult to obtain. At this time,
there is promise for NMES and pre-treatment therapy in concurrence with conventional
treatment during oral and pharyngeal phase dysphagia following radiation therapy. Since the
research in inconclusive, SLPs should continue to analyze research as it surfaces and adjust their
practice accordingly.

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