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Effects of Radiation on Swallowing

External-beam radiation has both early and late side effects that can impact swallowing function. Early effects include xerostomia, erythema superficial ulceration, bleeding, pain, and mucositis.[10,11] These usually result in oral pain that may cause only minimal diet alterations, require prescription of pain medications, or necessitate reliance on non-oral nutrition. Hypopharyngeal stricture may require dilation or surgery (Fig 3). Xerostomia is a side effect of treatment that persists for years and may worsen over time.[12] Late radiation effects may include osteoradionecrosis, trismus, reduced capillary flow, altered oral flora, dental caries, and altered taste sensation.[10,11,13,14,15,16] The late effect of reduced blood supply to the muscle can result in fibrosis, reduced muscle size, and the need for replacement with collagen.[17] This can dramatically affect swallowing years after treatment with a fixation of the hyolaryngeal complex, reduced tongue range of motion, reduced glottic closure, and cricopharyngeal relaxation, resulting in potential for aspiration.[18,19] Specific swallowing exercises have been shown to reduce these effects and improve prognosis for oral intake. These include jaw range of motion, tongue base range of motion exercises, and effortful swallow exercises,[20] tongue holding maneuver,[21] Mendelsohn maneuver,[22] and super supraglottic swallow.[23] Patients are encouraged to practice these exercises daily during and after treatment since effects of chemoradiation can occur long after treatment completion. As new delivery methods of radiation therapy are developed, such as shielding and intensity modulation, the negative effects of treatment should be reduced.

Figure 3.

Hypopharyngeal stricture may require dilation or surgery.

The speech pathologist, as part of the interdisciplinary team, should provide patient education about strategies to reduce the effects of radiation on swallowing. These strategies may include optimal oral hygiene, avoidance of alcohol and tobacco, decreased caffeine consumption, adequate hydration, avoidance of irritating food tastes or textures, and use of artificial saliva or saliva replacement medication. If dental caries are present, dental interventions such as full mouth extractions are considered prior to radiation therapy. Otherwise, daily mouth care, use of topical fluoride, and avoidance of foods that induce dental pain are recommended. In cases of severe osteoradionecrosis, patients are usually converted to a puree diet, liquid nutritional supplements are encouraged, and tube feeding may be required.