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Evaluation of Dysphagia in Head and Neck Cancer

A comprehensive evaluation of dysphagia should include several medical disciplines including the surgeon, medical oncologist, radiation oncologist, speech pathologist, radiologist, and dietitian. While each has a role to play, it is usually the speech pathologist who conducts a clinical or instrumental assessment of swallowing function and makes recommendations for therapeutic intervention. A thorough examination begins with a clinical swallow assessment that includes a detailed history of subjective complaints and medical status, pertinent clinical observations, and a physical examination. Swallowing trials can be initiated with a range of food textures. An oromotor examination assesses the function of the oral structures for swallowing. Blue dye testing can be utilized with patients who are tracheostomized to accurately determine the relative risk of aspiration.[1] Cervical auscultation uses a stethoscope on the larynx to detect the sounds of swallowing and respiration.[2] The goals of a clinical assessment are screening for the presence of dysphagia, contributing information as to the possible etiology of the impairment, determining the relative risk of aspiration, ascertaining the need for non-oral nutrition, and recommending additional assessment procedures.

Several instrumental assessments of swallowing exist to provide objective information about swallowing function and safety. The most widely used procedure is a videofluoroscopic assessment of swallowing.[3] It is performed in the radiology department by a radiologist and speech pathologist. Benefits include the ability to view the complex interaction of the phases of swallowing, describe the anatomy changes and dynamics of the swallow, identify the etiology of aspiration, and assess the benefit of treatment strategies during the study. The modified barium swallow is thought to be the "gold standard" for assessment of swallowing. However, the fiberoptic endoscopic evaluation of swallowing (FEES) is a useful tool in the assessment of swallowing in the head and neck cancer patient.[4,5,6] It consists of passing a thin, flexible endoscope into the pharynx and observing the act of swallowing. It provides excellent visualization of postsurgical or postradiation anatomical changes. It can also be used as biofeedback to retrain swallowing function. Scintigraphy,[7] manofluorography,[8] and ultrasound[9] have all been used as methods of assessment. However they are generally used as an adjunct to modified barium swallow or FEES rather than an alternative.

Instrumental assessment of swallowing in the head and neck cancer population provides useful information about both the structure and function of the swallowing mechanism. Patients with oral cavity lesions generally demonstrate swallowing symptoms specific to bolus preparation, containment, and posterior movement to the pharynx. Oral phase deficits that can be identified using the modified barium swallow include insufficient lip seal, impaired mastication, poor bolus control, oral stasis, premature leakage of foods to the pharynx, and structural abnormalities. Tumors located in the oropharynx and/or pharynx may demonstrate a delayed or absent swallow response, reduced pharyngeal contraction, reduced epiglottic inversion, decreased laryngeal elevation, or diminished or uncoordinated cricopharyngeal sphincter relaxation (Fig 1). Laryngeal penetration or tracheal aspiration may occur as a result of the aforementioned deficits ( Table and Fig 2).

Figure 1.

Post swallow oral (thick arrow) and pharyngeal (thin arrow) stasis in a patient with base of tongue cancer.

Figure 2.

Laryngeal penetration (thick arrow) or tracheal aspiration (thin arrow) may occur as a result of post swallow stasis in the valleculae.

Swallowing evaluation using FEES provides information regarding the structure and functions of the pharyngeal phase of swallowing. It offers optimal visualization of the tumor, reconstructed anatomy, and associated treatments, as well as their effects on swallowing. FEES also allows assessment of palatal function in patients with palatal resections and assists the maxillofacial prosthodontist in developing palatal obturators. It also permits inspection of secretion management, a known indicator of swallowing safety.