1. Dysphagia related to head & neck cancer intervention
Colby McCurdy, MM
Southeastern Louisiana University

2. Relevant Head & Neck Cancers
Squamous Cell Carcinoma
Tongue/Floor of Mouth
Mandibular
Laryngeal
Base of Tongue/Tonsillary
Differentiated from Tongue and Floor of Mouth due to unique etiology – HPV-16
225% increase in incidence from (Chaturvedi et al., 2011)

3. Interventions: from most conservative to most invasive
Chemotherapy
Type and Amount Determined by Surgeon or Oncologist
Radiation Therapy (XRT)
Typically 35 treatments over 7 weeks
Chemo + radiation
Adjuvant or Concurrent
Surgical Excision of Tumor (with or without adjuvant chemo)
Pathology Check for Clean Margins
Surgical Excision of Field Containing Tumor
Surgical Excision of Field + Radiation
Surgical Excision of Field + Chemo + Radiation
70% chance of ipsilateral cervical node metastasis, and a 30% chance of contralateral cervical node metastasis at the microscopic level (Choi et al., 2009; Mendenhall et al., 2011).

4. Effects of Chemotherapy on the swallowing mechanism and function
According to the American Society of Clinical Oncology (2005), Chemotherapy typically does not result in dysphagia, but may have other side effects, including :
Xerostomia
Infections of the mouth or esophagus due to a compromised immune system
Reduced appetite
General Fatigue

5. Effects of radiation therapy on the swallowing mechanism and function
Radiation therapy causes cell change at the level of the DNA. Therefore, cellular changes take place throughout the life span. Swallowing difficulties may begin immediately, or many years post- radiation.
Side effects include (ACS, 2016):
Soreness and/or open sores in the mouth or
throat
Xerostomia
Dysgeusia
Nausea
Tooth decay
Many pts have teeth extracted prior to
treatment
Mucositis
Trismus
Odynophagia
Oropharyngeal Dysphagia
Radiation Fibrosis
Changes in skin texture
Radiation Necrosis
Tissue death

6. Osteoradionecrosis of the mandible.
40 YO female post-laryngectomy w/chemoradiation. Intense fibrosis in the soft tissues of the neck and stricture formation in the pharynx leading to dysphagia.
Osteoradionecrosis of the mandible.

7. Effects of Surgical Excision on the swallowing mechanism and function
Phonosurgery of TVF lesion
Temporary incomplete adduction of the TVFs, resulting in incomplete airway closure
Risk for aspiration
Partial/Total Glossectomy
Reduced sensation and ROM of the tongue, particularly on the affected side
Reduced bolus manipulation and propulsion
Total Laryngectomy
Removal of laryngeal structures eliminates risk for aspiration, but also affects UES function because the larynx isn’t there to pull it open.

8. MBSS 4 years post-laryngectomy
Left partial glossectomy with forearm flap resection 

9. Role of the SLP in managing Dysphagia
Prior to treatment, educate patient about what to expect and acquire baseline function
Indirect therapy when applicable
Monitor for changes in weight
Make recommendations for ensuring adequate nutrition/hydration (w/nutritionist)
Chemoradiation:
Provide prophylactic swallow strengthening exercises and compensatory strategies for safe swallow
Myofascial release
oral care recommendations
Ongoing dysphagia therapy during and after treatment
Laryngectomy:
BOT retraction exercises and compensatory strategies if applicable
Re-train for taste & smell
Glossectomy/FOM Resection:
Lingual strengthening and ROM exercises
Provide swallow strengthening exercises and compensatory strategies
Work with prosthodontist for fitting of palatal drop

10. references
American Cancer Society (2016). Side effects from radiation therapy to the head and neck. Accessed from adiationtherapyaguideforpatientsandfamilies/understanding-radiation-therapy-radiation-to-head-and- neck
American Society of Clinical Oncology (2005). Difficulty swallowing or dysphagia. Accessed from
Chaturvedi AK, Engels EA, Pfeiffer RM, et al. (2011). Human papillomavirus and rising oropharyngeal cancer incidence in the United States [PubMed Abstract]. Journal of Clinical Oncology, 29(32):
Choi WH, Hu KS, Culliney B, et al. (2009). Cancer of the oropharynx. In: Harrison LB, Sessions RB, Hong WK, eds.: Head and Neck Cancer: A Multidisciplinary Approach. 3rd ed. Philadelphia, PA: Lippincott, William & Wilkins.
Mendenhall WM, Werning JW, Pfister DG (2011). Treatment of head and neck cancer. In: DeVita VT Jr, Lawrence TS, Rosenberg SA: Cancer: Principles and Practice of Oncology. 9th ed. Philadelphia, Pa: Lippincott Williams & Wilkins.