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 Table of Contents  
Year : 2020  |  Volume : 4  |  Issue : 3  |  Page : 133-137

Swallowing dysfunction after head-and-neck irradiation – Is it worth the fiberoptic endoscopic evaluation of swallowing?

1 Department of Radiotherapy, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India
2 Department of Radiotherapy, Christian Medical College and Hospital, Ludhiana, Punjab, India
3 Department of ENT, Christian Medical College and Hospital, Ludhiana, Punjab, India
4 Department of Radiodiagnosis, Christian Medical College and Hospital, Ludhiana, Punjab, India

Date of Submission24-Aug-2020
Date of Decision15-Sep-2020
Date of Acceptance24-Oct-2020
Date of Web Publication26-Nov-2020

Correspondence Address:
Romi Kant Grover
Department of Radiotherapy, Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/oji.oji_42_20

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Background: Treatment-related swallowing dysfunction still represents a significant clinical issue affecting the quality of life of head and neck cancer (HNC) patients following radiation therapy (RT) or chemoradiation therapy (CRT). Aim: The aim of the study was to evaluate the incidence of swallowing dysfunction following RT or CRT by fiberoptic endoscopic evaluation of swallowing (FEES) and to analyze the FEES findings in reference to patient-, tumor- and treatment-related factors. Materials and Methods: This prospective study included histopathological-proven HNC patients undergoing objective swallowing assessment by FEES at baseline, 3 months, and 6 months after receiving RT or CRT from December 2013 to November 2014. The parameters used to represent swallowing dysfunction included pooling of secretions, laryngeal penetration, aspiration, laryngopharynx reflux, and nasopharyngeal reflux. Results: A total of 34 patients undergoing a swallowing assessment schedule were analyzed. At 3-month assessment, we found swallowing dysfunction in 38.2% of cases which was more frequent in patients with oral cavity and hypopharyngeal primaries than other primary sites of HNC (P = 0.013). There was a higher chance of swallowing dysfunction among locally advanced HNC patients than early-staged patients, particularly at 3-month assessment although statistically insignificant (41.3% vs. 20%). The most frequently noted swallowing dysfunction was pooling of secretions in the vallecula and pyriform fossa. At 3 months following RT/CRT, there was an increase in the incidence of swallowing dysfunction (38.2% of patients) which subsequently decreased by 6 months (20.6% of patients). Conclusions: It is imperative to pick up the observations pointing toward the development of future swallowing dysfunction among HNC patients following RT/CRT by performing FEES, thereby reducing mortality associated with silent aspiration.

Keywords: Chemoradiotherapy, fiberoptic endoscopic evaluation of swallowing, head and neck neoplasms, incidence, quality of life

How to cite this article:
Grover RK, Negi P, Kingsley PA, Varghese A, George UB. Swallowing dysfunction after head-and-neck irradiation – Is it worth the fiberoptic endoscopic evaluation of swallowing?. Oncol J India 2020;4:133-7

How to cite this URL:
Grover RK, Negi P, Kingsley PA, Varghese A, George UB. Swallowing dysfunction after head-and-neck irradiation – Is it worth the fiberoptic endoscopic evaluation of swallowing?. Oncol J India [serial online] 2020 [cited 2021 Dec 5];4:133-7. Available from: https://www.ojionline.org/text.asp?2020/4/3/133/301586

  Introduction Top

The standard treatment of inoperable, locally advanced head-and-neck cancer (HNC) in the present scenario still remains a challenge. Among the various treatment options, concurrent chemoradiation therapy (CRT) is the mainstay of treatment for these patients.[1] Several meta-analyses on this approach have shown significant improvements in survival, although at the cost of increased toxicity.[2]

With this treatment option, critical structures required for normal swallowing process such as superior, middle, and inferior constrictor muscles, tongue, larynx, and cricopharyngeus muscle are prone to receive high radiation doses.[3] Radiotherapy-induced swallowing dysfunction is a common yet often underreported complication following treatment. All patients treated with CRT have similar swallowing dysfunction across all stages of swallowing, that is, oral preparatory, oral, pharyngeal, and esophageal phases of swallowing.[4] The incidence of acute and late swallowing dysfunction following CRT with altered fractionated three-dimensional conformal radiotherapy (3D-CRT) or intensity-modulated radiotherapy (IMRT) technique ranges from 15%–63% to 3%–21%, respectively.[5] In addition, swallowing dysfunction can result in silent aspiration in the oropharynx or hypopharynx at the end of the swallowing phase which may be then inhaled due to a decrease in cough reflex, proving fatal for the patient.[6]

This swallowing dysfunction following treatment is a major area of concern for the patients, as it has shown a detrimental effect on patient's quality of life.[7] There has been a controversy regarding the best method to assess the swallowing dysfunction because of some intrinsic problems. These include the timing of dysphagia, i.e., as an acute toxicity or late toxicity, and the exact definition of swallowing dysfunction. This can be evaluated using either objectively through invasive techniques such as videofluoroscopy or fiberoptic endoscopic evaluation of swallowing (FEES).[8]

It is of utmost importance to know the incidence of swallowing dysfunction by FEES and to correlate findings on FEES with various patient-, tumor- and treatment-related factors from pretreatment to early posttreatment so as to direct future efforts toward its prevention or its reduction.

  Materials and Methods Top

The present prospective observational study was conducted on patients with squamous cell carcinoma of head and neck with Karnofsky performance status ≥70 at Christian Medial College and Hospital, Ludhiana, in a 1-year period between December 2013 and November 2014. The study was approved by the Institutional Review Board and Institutional Ethics Committee (letter number: CMC/3159). Written informed consent had been obtained from all the patients. Patients with medical conditions such as neurological disease affecting swallowing function, previous history of RT/CRT for malignancy of head-and-neck region, those with baseline swallowing dysfunction, and those with tracheostomy were excluded from the study.

External-beam RT was delivered with either conventional or 3D-CRT technique with or without chemotherapy. A total dose of 66–70 Gy over 6.5–7 weeks was administered to all the patients with a spinal cord block after 40 Gy in 20 fractions when treating conventionally. With 3D-CRT technique, delineation of gross tumor volume, clinical target volume, planning target volume, and organs at risk volume, including the salivary glands, the superior, middle, and inferior pharyngeal constrictor muscles, the cricopharyngeus muscle, the cervical esophagus, base of the tongue, and the supraglottic and glottis larynx, were delineated as per the RT Oncology Group guidelines. Concurrent chemotherapy administered to all the CRT patients was either cisplatin 40 mg/m2 once every weekly for 5–6 cycles or 100 mg/m2 every three weekly for three cycles.

All patients underwent FEES evaluation with a flexible endoscope inserted through the nasal passage and passed transnasally into the hypopharynx to the level of vallecula or laryngeal vestibule where the oropharynx, pharynx, and larynx were viewed. Food and liquid boluses are then given to the patient so that the integrity of the pharyngeal phase of swallowing can be assessed. This examination provides the information on the ability to protect the airway, the ability to start a prompt swallow without spillage of food material into the hypopharynx, movement of the bolus through the hypopharynx, and ability to clear the bolus during the swallow, pooling of secretions, sensitivity of various structures, and the effect of anatomy on the swallow. This procedure, in addition, provided an image of the vocal folds, laryngeal and velopharyngeal structures, and upper pharyngeal physiology during swallowing, with the potential for image recording and instant replay. FEES was performed once before initiating treatment and at 3 months and 6 months following RT.

Various parameters were used in this study to represent swallowing dysfunction including pooling of secretions, laryngeal penetration, aspiration, laryngopharynx reflux, and nasopharyngeal reflux. Each of these FEES findings was analyzed in reference to patient, tumor and treatment characteristics. Information was obtained regarding a patient's ability to protect his airway for swallowing, appropriate diet and postures for feeding, and the need for further diagnostic swallowing studies. All patients were followed up monthly for a minimum period of 6 months.

The information related to sociodemographic variables and swallowing dysfunction was entered in the form of a data matrix in Microsoft® Excel® and analyzed using IBM® SPSS® v20.0 (IBM SPSS, Chicago, Illinois, USA). The descriptive statistics for categorical/ordinal variables are presented in the form of frequencies and percentages. Association between various factors and swallowing dysfunction was statistically analyzed using Chi-square test.

  Results Top

Thirty-eight patients with a histopathological diagnosis of head-and-neck squamous cell carcinoma received RT alone/CRT during the study period. Among these, 37 patients were eligible for inclusion in this study as one patient refused to give consent and were evaluated as per the protocol and staged according to the AJCC 2010 staging system. These patients were treated with RT. However, two patients died and one was lost to follow-up within 1–3 months following RT/CRT, and hence, swallowing function could not be assessed at 6 months. Hence, the data of a total number of 34 patients who underwent FEES at baseline, 3 months, and 6 months of follow-up were statistically analyzed.

The age at presentation ranged from 22 to 75 years, with a mean age of 54.5 ± 14.14 years. Among the common primary tumor sites, carcinoma of the oral cavity and oropharynx constituted 32.4% each, followed by other sites (14.7%) and larynx (11.8%) and least by carcinoma of the hypopharynx (8.8%). Majority of the patients had locally advanced tumors (85.3%) at the time of presentation. Nineteen (55.9%) patients were treated with conformal technique except 15 (44.1%) who were treated with a conventional technique. CRT formed the standard of care for 82.4% of patients as compared to 17.6% of patients treated with RT alone.

The most frequently noted disorder was pooling of secretion in vallecula and pyriform fossa on FEES [Table 1] and was of great diagnostic interest in the evaluation of subjects with swallowing dysfunction. This important finding can be underestimated in bedside evaluations of patients which is at risk for aspiration. On assessment of swallowing dysfunction with FEES, the incidence of swallowing dysfunction at 3 months was 38.2%. There was a decline in the incidence of swallowing dysfunction at 6 months (20.6%).
Table 1: Distribution of fiberoptic endoscopic evaluation of swallowing findings at 3-month and 6-month posttreatment

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In univariate analysis, swallowing dysfunction was found statistically significantly associated with the primary tumor site at 3-month posttherapy (P = 0.013). No statistically significant association was found for other variables such as stage of the disease (P = 0.681), treatment modality (P = 0.231), or radiation technique (P = 0.851) [Table 2].
Table 2: Association of patient-, tumor, and treatment-related factors with swallowing dysfunction on fiberoptic endoscopic evaluation of swallowing at 3 months

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Furthermore, we found that patients with primary tumor sites involving the oral cavity and hypopharynx had more swallowing dysfunction 6-month posttherapy, although not statistically significant (P = 0.066). At 6-month assessment, no statistically significant association of swallowing dysfunction was found for the other variables such as stage of the disease (P = 0.573), treatment modality (P = 0.793), or radiation technique (P = 0.940). Thus, we found no statistically significant association between patient-, tumo, and treatment-related factors with swallowing dysfunction at 6-month posttherapy [Table 3].
Table 3: Association of patient-, tumor-, and treatment-related factors with swallowing dysfunction on fiberoptic endoscopic evaluation of swallowing at 6 months

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  Discussion Top

Swallowing dysfunction is a common outcome after RT treatment for head-and-neck malignancy affecting the nutritional status and quality of life of these patients.[9] This swallowing dysfunction can occur as acute/late toxicity as a consequence of treatment.[10] FEES is the most commonly used method for the objective assessment of pharyngeal phase of the swallowing.[11] Studies have reported that the frequency and severity of this pretreatment dysphagia depend on tumor stage and localization.[12] Patients having pretreatment swallowing dysfunction are at a greater risk for chronic swallowing dysfunction posttreatment.[13]

We found that 72.7% of patients with primary involving the oral cavity and 66.7% of patients with hypopharyngeal primary had swallowing dysfunction at 3-month post-treatment. These results are in line with a study by Pezdirec et al. that reported dysphagia in 57.6% of patients treated for cancer of the oral cavity or oropharynx, 39.2% of patients treated for cancer of the hypopharynx or larynx, and in 26.7% of patients treated for unknown primary tumor and 20% patients treated for cancer of the nasal cavity, paranasal sinuses, or nasopharynx.[14]

We observed that 38.2% of our patients had swallowing dysfunction in the form of pooling of secretions in the vallecula/pyriform fossa, being the most common finding noted. The incidence of swallowing dysfunction in our study was 38.2% which is quite low in comparison to other studies. The possible explanation for this could be the distribution of primary tumor sites and the method used for dysphagia assessment.

We observed that swallowing dysfunction is more frequent in patients presenting with locally advanced (Stage III–IV) tumors at 3 months following treatment. This is in concordance with Langendijk et al. which reported patients with locally advanced tumors having severe swallowing dysfunction.[15]

Swallowing dysfunction still remains a potentially life-threatening complication in HNC patients treated with RT or CRT even with modern RT techniques. Eisbruch et al. reported dysphagia–aspiration-related structures (DARSs) whose treatment-induced damage results in swallowing dysfunction.[16] This includes the pharyngeal constrictor muscles, supraglottic larynx, and glottis larynx. Conformal techniques have been utilized to selectively decrease RT dose to these structures.[17] At 3 months, swallowing dysfunction was 40.0% for conventional arm and 36.8% in 3D-CRT arm which was a nearly similar result but with a slightly higher chance of swallowing dysfunction in conventional arm (P = 0.851). Retrospective analysis on swallowing function of patients with carcinoma anterior two-third of the tongue, treated with IMRT versus conventional RT, by Prameela et al. concluded that there is an existing relation between the dose received by the swallowing structures and dysphagia.[18]

We found a higher trend of swallowing dysfunction in patients receiving combined modality treatment in the form of CRT with compared to RT alone, although statistically insignificant. There are studies reporting on that the addition of chemotherapy to RT can result in an increase in the incidence of acute toxicities including swallowing dysfunction.[17]

We found that impairments of swallowing function increased at 3 months because of associated RT-induced mucosal damage and reduced in incidence at 6-month posttreatment on FEES examination. A thorough literature search has revealed that swallowing dysfunction may persist for decades after treatment and it continues to deteriorate years after treatment with chemoradiation due to progressive fibrosis in the irradiated tissues of the head and neck.[19]

There are certain limitations of this study including a small number of patients and shorter follow-up duration.

  Conclusions Top

Swallowing dysfunction in patients receiving head-and-neck irradiation is inevitable, but the incidence, severity, and its impact on the quality of life can be controlled by employing conformal techniques, early diagnosis, and introduction of rehabilitation. It is challenging to ensure optimal homogenous dose delivery to tumor volume while sparing the DARS efficiently and thereby mitigate the development of swallowing dysfunction in this cohort of patients due to the complexity of the anatomical structures involved in HNC and/or adjacent healthy tissues. Hence, we conclude that it is of utmost importance to pick up the observations pointing toward the development of future swallowing dysfunction by performing FEES, an objective assessment of the pharyngeal phase of swallowing at baseline and periodically during follow-up, thereby reducing the mortality associated with silent aspiration.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Iqbal MS, Chaw C, Kovarik J, Aslam S, Jackson A, Kelly J, et al. Primary concurrent chemoradiation in head and neck cancers with weekly cisplatin chemotherapy: Analysis of compliance, toxicity and survival. Int Arch Otorhinolaryngol 2017;21:171-7.  Back to cited text no. 1
Forastiere AA, Goepfert H, Maor M, Pajak TF, Weber R, Morrison W, et al. Concurrent chemoradiotherapy and radiotherapy for organ preservation in advanced laryngeal cancer. N Engl J Med 2003;349:2091-8.  Back to cited text no. 2
Levendag PC, Teguh DN, Voet P, van der Est H, Noever I, de Kruijf WJ, et al. Dysphagia disorders in patients with cancer of the oropharynx are significantly affected by the radiation therapy dose to the superior and middle constrictor muscle: A dose-effect relationship. Radiother Oncol 2007;85:64-73.  Back to cited text no. 3
Pauloski BR. Rehabilitation of dysphagia following head and neck cancer. Phys Med Rehabil Clin N Am 2008;19:889-928, x.  Back to cited text no. 4
Peponi E, Glanzmann C, Willi B, Huber G, Studer G. Dysphagia in head and neck cancer patients following intensity modulated radiotherapy (IMRT). Radiat Oncol 2011;6:1.  Back to cited text no. 5
Caudell JJ, Schaner PE, Meredith RF, Locher JL, Nabell LM, Carroll WR, et al. Factors associated with long-term dysphagia after definitive radiotherapy for locally advanced head-and-neck cancer. Int J Radiat Oncol Biol Phys 2009;73:410-5.  Back to cited text no. 6
Rogers SN, Heseltine N, Flexen J, Winstanley HR, Cole-Hawkins H, Kanatas A. Structured review of papers reporting specific functions in patients with cancer of the head and neck: 2006-2013. Br J Oral Maxillofac Surg 2016;54:e45-51.  Back to cited text no. 7
Erkal EY, Canoǧlu D, Kaya A, Aksu G, Sarper B, Akansel G, et al. Assessment of early and late dysphagia using videofluoroscopy and quality of life questionnaires in patients with head and neck cancer treated with radiation therapy. Radiat Oncol 2014;9:137.  Back to cited text no. 8
Kraaijenga SA, Oskam IM, van Son RJ, Hamming-Vrieze O, Hilgers FJ, van den Brekel MW, et al. Assessment of voice, speech, and related quality of life in advanced head and neck cancer patients 10-years+after chemoradiotherapy. Oral Oncol 2016;55:24-30.  Back to cited text no. 9
Christianen ME, Verdonck-de Leeuw IM, Doornaert P, Chouvalova O, Steenbakkers RJ, Koken PW, et al. Patterns of long-term swallowing dysfunction after definitive radiotherapy or chemoradiation. Radiother Oncol 2015;117:139-44.  Back to cited text no. 10
Dziewas R, auf dem Brinke M, Birkmann U, Warnecke T. Safety and clinical impact of FEES-results of the FEES-registry. Neurol Res Pract 2019;1:16.  Back to cited text no. 11
Logemann JA, Rademaker AW, Pauloski BR, Lazarus CL, Mittal BB, Brockstein B, et al. Site of disease and treatment protocol as correlates of swallowing function in patients with head and neck cancer treated with chemoradiation. Head Neck 2006;28:64-73.  Back to cited text no. 12
Dirix P, Abbeel S, Vanstraelen B, Hermans R, Nuyts S. Dysphagia after chemoradiotherapy for head-and-neck squamous cell carcinoma: Dose-effect relationships for the swallowing structures. Int J Radiat Oncol Biol Phys 2009;75:385-92.  Back to cited text no. 13
Pezdirec M, Strojan P, Boltezar IH. Swallowing disorders after treatment for head and neck cancer. Radiol Oncol 2019;53:225-30.  Back to cited text no. 14
Langendijk JA, Doornaert P, Rietveld DH, Verdonck-de Leeuw IM, Leemans CR, Slotman BJ. A predictive model for swallowing dysfunction after curative radiotherapy in head and neck cancer. Radiother Oncol 2009;90:189-95.  Back to cited text no. 15
Eisbruch A, Schwartz M, Rasch C, Vineberg K, Damen E, Van As CJ, et al. Dysphagia and aspiration after chemoradiotherapy for head-and-neck cancer: Which anatomic structures are affected and can they be spared by IMRT? Int J Radiat Oncol Biol Phys 2004;60:1425-39.  Back to cited text no. 16
Batth SS, Caudell JJ, Chen AM. Practical considerations in reducing swallowing dysfunction following concurrent chemoradiotherapy with intensity-modulated radiotherapy for head and neck cancer. Head Neck 2014;36:291-8.  Back to cited text no. 17
Prameela CG, Ravind R, Renil Mon PS, Sheejamol VS, Dinesh M. Radiation dose to dysphagia aspiration-related structures and its effects on swallowing: Comparison of three-dimensional conformal radiotherapy and intensity-modulated radiation therapy plans. J Cancer Res Ther 2016;12:845-51.  Back to cited text no. 18
Bleier BS, Levine MS, Mick R, Rubesin SE, Sack SZ, McKinney K, et al. Dysphagia after chemoradiation: Analysis by modified barium swallow. Ann Otol Rhinol Laryngol 2007;116:837-41.  Back to cited text no. 19


  [Table 1], [Table 2], [Table 3]


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