Association of Tongue Strength and Maximum Incisal Opening with Oral Intake in Persons with Head and Neck Cancer Treated with Radiotherapy: A Retrospective Study.

Persons treated with radiotherapy (RT) for cancer of the head and neck (HNC) may experience limited oral intake at treatment completion. The purpose of this retrospective study was to examine the contributions of tongue strength and maximum incisal opening (MIO) to oral intake in a cohort of veterans treated for HNC. Medical records of veterans diagnosed with HNC treated with RT who were seen by the Speech Pathology Service prior to and throughout treatment per usual care were reviewed for this study; eighty-two records met the inclusion criteria for analysis. Tongue strength in kPa, MIO in mm, feeding tube status at completion of RT, and food and liquid consistencies consumed at completion of RT were among the data abstracted from the records. Most veterans (67%) did not have a feeding tube present at the completion of RT and reported drinking thin liquids (84.2%) at treatment completion. Eighteen percent reported including all food consistencies in their diet at the end of treatment. Both MIO and tongue strength decreased after treatment. Greater tongue strength during RT and larger MIO at the completion of RT were predictive of improved functional outcomes for oral intake at the end of treatment. This study provides evidence of the importance of increasing tongue strength and MIO during treatment with RT, and supports an important focus for intervention by speech-language pathologists.

Efficacy of electrical stimulation and exercise for dysphagia in patients with head and neck cancer: A randomized clinical trial.

BACKGROUND: Neuromuscular electrical stimulation (NMES) is a highly sought after but poorly studied treatment for dysphagia among patients with head and neck cancer with dysphagia. This study investigated the efficacy of NMES in this patient population. METHODS: In this double-blinded, randomized controlled trial, 170 patients with head and neck cancer experiencing posttreatment dysphagia were randomized into active NMES + swallow exercise versus sham NMES + swallow exercise groups. Outcomes after a 12-week program included changes in fluoroscopy measures, diet, and quality of life. RESULTS: After the 12-week program, the active NMES group had significantly worse Penetration Aspiration Scale scores than the sham group. Both groups reported significantly better diet and quality of life. No other measures were significant. CONCLUSION: NMES did not add benefit to traditional swallow exercises. Unfortunately, swallow exercises were not effective by themselves either. For patients with head and neck cancer with moderate to severe dysphagia caused by radiation therapy, current behavioral therapies are of limited help in reversing long-term dysphagia. © 2015 Wiley Periodicals, Head Neck 38: E1221-E1231, 2016.

Effect of induction chemotherapy on swallow physiology and saliva production in patients with head and neck cancer: a pilot study.

BACKGROUND: No objective data are available to assess the potential damage induction chemotherapy alone contributes to swallowing physiology and salivary production in patients with locally and regionally confined head and neck cancer. METHODS: Thirteen patients with head and neck cancer were evaluated preinduction and postinduction chemotherapy. Assessment included: (1) percentage of nutrition taken orally and food consistencies in diet; (2) videofluorographic swallow evaluation; (3) whole mouth saliva collection; (4) quality-of-life questionnaire; and (5) pain and oral mucositis scores. RESULTS: All patients were able to consume most foods and took 100% of their nutrition orally both preinduction and postinduction chemotherapy. Although a number of swallow measures worsened, no statistically significant differences were observed in diet, quality of life measures, pain, or saliva weight, or in most temporal swallow measures. Pharyngeal residue decreased significantly after chemotherapy. CONCLUSION: Induction chemotherapy alone did not significantly negatively alter swallowing physiology and salivary secretion, although the trend was toward worsening in function.

Comparison of swallowing function after intensity-modulated radiation therapy and conventional radiotherapy for head and neck cancer.

BACKGROUND: Intensity-modulated radiotherapy (IMRT) is hoped to protect structures important for swallow function. We compared posttreatment swallow function in 7 pairs of patients with head and neck cancer treated with either IMRT or conventional radiotherapy (RT). METHODS: Patients were matched on tumor characteristics. Swallowing function was evaluated with the modified barium swallow procedure pretreatment and at 3 and 6 months postcancer treatment completion. Swallows were analyzed for bolus transit times, bolus residues, laryngeal closure (LAC) duration, cricopharyngeal opening (CPO) duration, and oropharyngeal swallow efficiency (OPSE). Data were analyzed using multifactor repeated measures analysis of variance and adjusted for baseline function. RESULTS: Main effect of radiation type was significant for all measures on at least 1 bolus type. Patients treated with IMRT demonstrated shorter bolus transit times, less oral and pharyngeal residue, longer LAC, and larger OPSE. CONCLUSION: Patients treated with IMRT demonstrated faster, more efficient swallows, and greater airway protection.

Effects of enhanced bolus flavors on oropharyngeal swallow in patients treated for head and neck cancer.

BACKGROUND: Treatment for head and neck cancer can reduce peripheral sensory input and impair oropharyngeal swallow. This study examined the effect of enhanced bolus flavor on liquid swallows in these patients. METHODS: Fifty-one patients treated for head and neck cancer with chemoradiation or surgery and 64 healthy adult control subjects served as subjects. All were randomized to receive sour, sweet, or salty bolus flavor. Patients were evaluated at 7-10 days, 1 month, and 3 months after completion of tumor treatment. Control subjects received 1 assessment. RESULTS: All bolus flavors affected oropharyngeal swallow; sour flavor significantly shortened pharyngeal transit time across all evaluations. CONCLUSIONS: Sour flavor influenced the swallow of patients treated for head and neck cancer, as well as that of control subjects in a manner similar to those with neurologic impairment observed in an earlier study. Sour flavor may improve the speed of pharyngeal transit regardless of whether a patient has suffered peripheral or central sensory damage.

Relation of mucous membrane alterations to oral intake during the first year after treatment for head and neck cancer.

BACKGROUND: Acute oral mucositis is associated with pain and impaired swallowing. Little information is available on the effects of chronic mucositis on swallowing. METHODS: Sixty patients treated for cancer of the head and neck were examined during the first year after their cancer treatment. Oral mucosa was rated with the Oral Mucositis Assessment Scale. Stimulated whole-mouth saliva, oral pain rating, percent of oral intake, and 2 subscales of the Performance Status Scale for Head and Neck (PSS-HN) cancer were also collected. RESULTS: Mucositis scores and pain ratings decreased over time while functional measures of eating improved over time. Reduction in chronic mucositis was correlated with improved oral intake and diet. CONCLUSION: Lack of association with pain was attributed to the absence of ulcerations. Continued impairment of oral intake during the first year posttreatment may be related to oral mucosal changes and other factors.

A randomized study comparing the Shaker exercise with traditional therapy: a preliminary study.

Seven institutions participated in this small clinical trial that included 19 patients who exhibited oropharyngeal dysphagia on videofluorography (VFG) involving the upper esophageal sphincter (UES) and who had a 3-month history of aspiration. All patients were randomized to either traditional swallowing therapy or the Shaker exercise for 6 weeks. Each patient received a modified barium swallow pre- and post-therapy, including two swallows each of 3 ml and 5 ml liquid barium and 3 ml barium pudding. Each videofluorographic study was sent to a central laboratory and digitized in order to measure hyoid and larynx movement as well as UES opening. Fourteen patients received both pre-and post-therapy VFG studies. There was significantly less aspiration post-therapy in patients in the Shaker group. Residue in the various oral and pharyngeal locations did not differ between the groups. With traditional therapy, there were several significant increases from pre- to post-therapy, including superior laryngeal movement and superior hyoid movement on 3-ml pudding swallows and anterior laryngeal movement on 3-ml liquid boluses, indicating significant improvement in swallowing physiology. After both types of therapy there is a significant increase in UES opening width on 3-ml paste swallows.

Relationship between manometric and videofluoroscopic measures of swallow function in healthy adults and patients treated for head and neck cancer with various modalities.

Pharyngeal manometry complements the modified barium swallow with videofluoroscopy (VFS) in diagnosing pressure-related causes of dysphagia. When manometric analysis is not feasible, it would be ideal if pressure information about the swallow could be inferred accurately from the VFS evaluation. Swallowing function was examined using VFS and concurrent manometry in 18 subjects (11 head and neck patients treated with various modalities and 7 healthy adults). Nonparametric univariate and multivariate analyses revealed significant relationships between manometric and fluoroscopic variables. Increases in pressure wave amplitude were significantly correlated with increased duration of tongue base to pharyngeal wall contact, reduced bolus transit times, and oropharyngeal residue. Pharyngeal residue was the most important VFS variable in reflecting pharyngeal pressure measurements. Certain VFS measures were significantly correlated with measures of pressure assessed with manometry. Further research is needed before observations and measures from VFS alone may be deemed sufficient for determining pressure-generation difficulties during the swallow in patients who are unable or unwilling to submit to manometric testing.

The Feasibility of Establishing Agreement Between Laboratories for Measures of Oropharyngeal Structural Movements.

Kinematic analysis, also commonly referred to as biomechanical analysis, of the swallow is used to measure movement of oropharyngeal structures over time. Two laboratory directors who have used kinematic analysis in their research collaborated to determine the feasibility of establishing agreement between two separate laboratories on measures of structural movements of the swallow. This report describes the process that was followed toward the goal of establishing measurement agreement. Under the direction of the laboratory directors, one research technician from each laboratory participated in a process that included initial meetings, training sessions, and pre- and post-training evaluation of reproducibility.Because agreement on initial measures of structural movement demonstrated weak correlation on some measures, the research technicians trained together for approximately 6 hours. After training, statistical analyses indicated that (a) most Pearson correlations for measures of structural movements were greater than 0.80 and were highly statistically significant; (b) most percentages of absolute deviation were under 25%; and (c) most concordance coefficients were above .70. These statistics indicate that the two laboratories were able to increase their level of agreement in measuring selected structural movements of the swallow after a brief amount of training.Factors affecting measurement agreement include image quality, establishment of rules for measuring, and the opportunity for regular discussions among research assistants and investigators from both laboratories.

What information do clinicians use in recommending oral versus nonoral feeding in oropharyngeal dysphagic patients?

There is little evidence regarding the type(s) of information clinicians use to make the recommendation for oral or nonoral feeding in patients with oropharyngeal dysphagia. This study represents a first step toward identifying data used by clinicians to make this recommendation and how clinical experience may affect the recommendation. Thirteen variables were considered critical in making the oral vs. nonoral decision by the 23 clinicians working in dysphagia. These variables were then used by the clinicians to independently recommend oral vs. nonoral feeding or partial oral with nonoral feeding for the 20 anonymous patients whose modified barium swallows were sent on a videotape to each clinician. Clinicians also received data on the 13 variables for each patient. Results of clinician agreement on the recommendation of full oral and nonoral only were quite high, as measured by Kappa statistics. In an analysis of which of the 13 criteria clinicians used in making their recommendations, amount of aspiration was the criterion with the highest frequency. Recommendations for use of postures and maneuvers and the effect of clinician experience on these choices were also analyzed.

Swallowing disorders in the first year after radiation and chemoradiation.

BACKGROUND: Radiation alone or concurrent chemoradiation can result in severe swallowing disorders. This manuscript defines the swallowing disorders occurring at pretreatment and 3 and 12 months after completion of radiation or chemoradiation. METHODS: Forty-eight patients (10 women and 38 men) participated in this study involving videofluorographic evaluation of oropharyngeal swallow at the 3 time points. RESULTS: At baseline, patients had some swallow disorders, probably related to presence of their tumor. At 3 months posttreatment, frequency of reduced tongue base retraction, slow or delayed laryngeal vestibule closure, and reduced laryngeal elevation increased from baseline. Some disorders continued at 12 months posttreatment. Functional swallow decreased over time in patients treated with chemoradiation, but not those treated with radiation alone. DISCUSSION: Chemoradiation results in fewer functional swallowers than radiation alone at 12 months posttreatment completion.

Effects of radiotherapy with or without chemotherapy on tongue strength and swallowing in patients with oral cancer.

BACKGROUND: Oral tongue strength and swallowing ability are reduced in patients treated with chemoradiotherapy for oral and oropharyngeal cancer. METHODS: Patients with oral or oropharyngeal cancer treated with high-dose chemoradiotherapy underwent tongue strength, swallowing, and dietary assessments at pretreatment and 1, 3, 6, and 12 months posttreatment. Tongue strength was assessed using the Iowa Oral Performance Instrument (IOPI). Oral and pharyngeal residue was evaluated utilizing videofluoroscopy. RESULTS: Mean maximum tongue strength dropped a nonsignificant amount immediately after treatment, and then increased significantly at 6- and 12-months posttreatment completion. Analyses were adjusted for patient dropout. Tongue strength was not significantly correlated with swallow observations of percentage oral and pharyngeal residue. Ability to eat various diet consistencies was reduced after treatment but improved over time at a rate similar to changes in oral intake and type of diet. CONCLUSIONS: Parallel but not significant changes in oral intake, diet, and tongue strength in the first year post chemoradiation therapy need further study in a larger population.

Relationship between swallow motility disorders on videofluorography and oral intake in patients treated for head and neck cancer with radiotherapy with or without chemotherapy.

BACKGROUND: Current research demonstrates that swallow function is impaired after treatment with organ-sparing chemoradiotherapy. Few studies, however, have related observed swallowing disorders with the patient's oral intake and diet in a large cohort of patients. METHODS: Swallowing function was examined using the modified barium swallow (MBS) procedure in 170 patients treated with radiotherapy with or without chemotherapy for cancer of the head and neck at 5 evaluation points: pretreatment and at 1, 3, 6, and 12 months posttreatment. Fisher's exact test was used to examine the relationship between swallow motility disorders and oral intake or diet consistencies. RESULTS: Limitations in oral intake and diet during the first year after cancer treatment were significantly related to reduced laryngeal elevation, reduced cricopharyngeal opening, and rating of nonfunctional swallow on at least 1 swallow of any bolus type. CONCLUSIONS: Swallow motility disorders had a significant impact on the eating ability of patients after treatment for head and neck cancer with radiotherapy with or without chemotherapy.

Site of disease and treatment protocol as correlates of swallowing function in patients with head and neck cancer treated with chemoradiation.

BACKGROUND: The relationship between type of chemoradiation treatment, site of disease, and swallowing function has not been sufficiently examined in patients with head and neck cancer treated primarily with chemoradiation. METHODS: Fifty-three patients with advanced-stage head and neck cancer were evaluated before and 3 months after chemoradiation treatment to define their swallowing disorders and characterize their swallowing physiology by site of lesion and chemoradiation protocol. One hundred forty normal subjects were also studied. RESULTS: The most common disorders at baseline and 3 months after treatment were reduced tongue base retraction, reduced tongue strength, and slowed or delayed laryngeal vestibule closure. Frequency of functional swallow did not differ significantly across disease sites after treatment, although frequency of disorders was different at various sites of lesion. The effects of the chemotherapy protocols were small. CONCLUSIONS: The site of the lesion affects the frequency of occurrence of specific swallow disorders, whereas chemoradiation protocols have minimal effect on oropharyngeal swallow function.

The relationship between observations and measures of oral and pharyngeal residue from videofluorography and scintigraphy.

We examined measures of oral and pharyngeal residues from scintigraphic studies and estimates/observations from videofluorographic (modified barium swallow) studies taken on the same day but not concurrently in 16 dysphagic patients of varying etiologies presenting with oral and/or pharyngeal dysphagia. Oral and pharyngeal residuals following the swallow were quantified scintigraphically and were then compared with measures of residuals obtained from the modified barium swallow. Estimates of oral and pharyngeal residues from the modified barium swallows were generated by a trained observer who was blinded to the scintigraphic data. Positive and significant Spearman correlations between oral and pharyngeal residue measures from scintigraphy and observations of oral and pharyngeal residues from modified barium swallows were found. This supports the validity of observations of oral and pharyngeal residues in clinical studies. Limitations of these observations are discussed.

Beyond efficacy and effectiveness: conducting economic analyses during clinical trials.

Few studies have examined cost issues in the field of dysphagia. This study presents cost data collected during a clinical trial in speech-language pathology, demonstrating the types of cost analyses that can be conducted and highlighting obstacles and issues facing investigators who seek to conduct economic analyses in this arena. Seventy-nine patients were enrolled in the clinical trial to assess the impact of a swallowing intervention on swallowing and speech function. The patients were at least one year past treatment for head and neck cancer. No significant intervention differences were detected in these outcomes. A companion economic analysis was conducted in 37 of these patients using patient diaries and followup with identified health care providers. Analyses indicated that (1) the intervention did not significantly reduce health care expenditures; (2) indirect costs and costs of hospitalizations are both important factors to consider during a trial; and (3) health care costs of this population are high relative to the rest of the U.S. population. Attrition from the overall study population can pose a serious threat to the viability of an economic study. The article concludes with a discussion of how these issues can be addressed in future studies.

Surgical variables affecting swallowing in patients treated for oral/oropharyngeal cancer.

BACKGROUND: Postoperative swallowing function may be influenced by a number of treatment variables; this study examines the relationship of various treatment factors to measures of swallow function. METHODS: Swallowing was examined with the modified barium swallow procedure in 144 patients surgically treated for oral or oropharyngeal cancer 3 months after healing. Univariate and multivariate correlations were used to examine the relationship between swallowing function and treatment. RESULTS: Percent tongue base resected and total volume resected were most often correlated with swallowing function in the univariate analyses. Multivariate analyses identified the following combinations with the strongest correlations: (1) percent tongue base resected and closure type for liquids; (2) percent tongue base resected and unreconstructed mandible for pastes; (3) total volume resected, percent lateral floor of mouth resected, and postoperative radiotherapy dose for masticated boluses. CONCLUSIONS: Total volume resected and percent tongue base resected had a profound impact on postoperative swallowing function. Combinations of percent tongue base resected with other surgical variables had the strongest relationships with overall swallowing function.

Prioritizing treatment outcomes: head and neck cancer patients versus nonpatients.

BACKGROUND: Treatment decisions in head and neck cancer (HNC) might involve consideration of uncertain tradeoffs of one late effect against another or increasing toxicity or residual impairment for increased chance of survival. Understanding how patients prioritize potential outcomes, as well as whether these preferences are similar to those of nonpatients, is important to informed decision making and treatment planning. METHODS: Two hundred forty-seven newly diagnosed HNC patients from nine institutions and 131 nonpatients rank ordered a set of 12 potential treatment outcomes (eg, cure; being able to swallow; normal voice) from highest (1) to lowest (12). RESULTS: Patients and nonpatients were similar with respect to the three items most frequently ranked in the top three, that is, "being cured of cancer," "living as long as possible," and "having no pain" in that order. In contrast, patients more frequently ranked "cure" (90% vs 80%) and less frequently ranked "no pain" (34% vs 52%) in the top three. CONCLUSIONS: Survival seems to be of paramount importance to both patient and nonpatient groups, overshadowing associated toxicities and potential dysfunction. At the same time, patients might be more willing than nonpatients to undergo aggressive treatments and endure acute distress in the interest of potential long-term gains (ie, cure or longer survival).

Eating ability in head and neck cancer patients after treatment with chemoradiation: a 12-month follow-up study accounting for dropout.

BACKGROUND: Head and neck cancer patients treated with chemoradiation have difficulty eating a normal diet. This study was designed to characterize eating ability over 12 months after chemoradiation treatment. Analyses take patient dropout into account. METHODS: Two hundred fifty-five patients with head and neck cancer treated with chemoradiation were followed for 12 months. Eating ability was analyzed using generalized linear model methods that accounted for non-ignorable dropout. RESULTS: Eating ability was compromised immediately after treatment and improved over 12 months to near pretreatment levels. Ability to eat at most 50% of the diet orally did not return to baseline levels (p <.05). However, the percent of patients eating a normal diet did return to baseline levels. Accounting for dropout modified the results, but the pattern of significance was similar. CONCLUSIONS: Treatment of head and neck cancer with chemoradiation has a significant effect on eating ability, which improves after 12 months after treatment.

Xerostomia: 12-month changes in saliva production and its relationship to perception and performance of swallow function, oral intake, and diet after chemoradiation.

BACKGROUND: Previous investigators have found permanent changes in saliva production after chemoradiation but have not examined these in relation to swallowing measures, diet changes, and patient comfort over time. METHODS: Thirty patients with advanced stage cancer of the oropharynx treated with chemoradiation were followed with videofluoroscopic swallow studies, a measure of stimulated total saliva production, a questionnaire of their perception of dry mouth, and a questionnaire on the nature of their oral intake at pretreatment until 12 months after treatment. RESULTS: Saliva declined significantly from pretreatment to 12 months. Swallowing-related complaints increased significantly over the 12 months, especially in patients with lower saliva weights. Diet choices increased over time after treatment, except crunchy foods. Swallow measures did not relate to saliva weight. CONCLUSIONS: Reduced saliva weight does not correlate with slowed or inefficient swallow. Instead, reduced saliva weight seems to change patients' perceptions of their swallowing ability and, on that basis, their diet choices.