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Treatment Strategies for Dysphagia

For those patients who have undergone surgical resection or organ preservation protocols for head and neck cancer and who are unable to resume functional swallowing, several treatment options are available. Treatment strategies should be introduced during the videofluoroscopic evaluation to determine the effectiveness of the strategy prior to implementation. Several categories of interventions exist including postural changes, sensory procedures, maneuvers, diet changes, physiologic exercise, and orofacial prosthetics. Used alone or in combination, these options can be extremely successful in returning a patient to safe and efficient oral intake.

Postural strategies are simple techniques designed to alter the bolus flow. A chin down posture improves base of tongue contact to the posterior pharyngeal wall, opens the vallecular space, and puts the larynx in a more protected position.[44] Head rotation to the damaged side closes off a weakened pharynx and allows bolus passage down the intact contralateral side.[45] Head tilt to the intact side provides gravity assist in bolus flow through the oral cavity and pharynx. A sidelying position may be useful in a delayed swallow or with poor airway protection as it slows the flow of the bolus through the pharynx. Combinations of these strategies can be used with an additive effect.

Sensory procedures provide altered sensory feedback or sensory enhancement during swallowing. Alterations in bolus volume, taste, and temperature can be used to affect changes in swallowing physiology. For example, cold and added pressure (thermal-tactile stimulation) have been shown to increase the speed of initiation of the swallow response.[46] Added pressure on the tongue by a utensil also increases sensory feedback. Since chewing sends sensory information to the pharynx, a soft masticated diet should be utilized when possible. Finally, the sensory motor integration achieved during self-feeding helps to normalize swallow patterns. Therefore, patients should feed themselves whenever possible.

Extensive data exist regarding the efficacy of swallowing maneuvers in the head and neck population. They are designed to alter the physiology of the swallow. The supraglottic swallow maneuver closes the vocal folds before and during the swallow.[23] The effortful swallow improves tongue base retraction and pressure generation.[22] The Mendelsohn maneuver enhances and prolongs laryngeal elevation and anterior movement to improve laryngeal elevation and extent and duration of cricopharyngeal opening.[22] The tongue-holding maneuver improves the tongue base to posterior pharyngeal wall contact and exercises the glossopharyngeal muscle.[21] Dry or repeated swallows reduce pharyngeal residues.

Diet alterations and food presentation strategies also can be use therapeutically to improve efficiency and safety of swallowing. Thickening liquids may slow the rate of bolus flow through the pharynx for patients with a delayed swallow. A puree diet can be used if surgical resection or trismus prevents chewing. Foods prepared with sauces and gravies may be useful for a xerostomic patient. Alternating solids and liquids can reduce pharyngeal stasis. Liquids can be presented by cup, straw, spoon, or syringe, depending on specific patient needs. Chopsticks or an iced teaspoon can place foods in the posterior oral cavity. A glossectomy spoon is specially designed to push food into the pharynx, bypassing the oral phase of swallow. Food placement on the surgically unaffected side can increase efficiency and safety as well. All of these dietary changes can be used in combination with postural alterations and swallow maneuvers at mealtime.

Range of motion exercises for the jaw, lips, oral tongue, tongue base, upper airway closure, and laryngeal elevation are useful for head and neck cancer patients who have structural or tissue damage. Resistance exercises are used for strengthening musculature. Exercises can be enhanced with new technology and devices. The Therabite (Therabite Corp, West Chester, Penn) improves jaw range of motion in patients with trismus (Fig 4). The Swallowing Workstation (Kay Elemetrics Corp, Pine Brook, NJ) provides biofeedback for a range of treatment applications (Fig 5). Surface electromyography (EMG) biofeedback provides visual and auditory feedback for added motivation and success during therapy. Surface EMG combined with respiratory tracing can provide feedback on the coordination between respiration and swallowing. Videoendoscopy can be used to view vocal fold closure associated with swallowing. Intraoral tongue array sensors provide visual biofeedback during tongue-strengthening exercises.

Figure 4.

The Therabite rehabilitation system improves jaw range of motion in patients with trismus. Copyright Therabite Corp, West Chester, Pa. Reprinted with permission.

Figure 5.

The Swallowing Workstation provides biofeedback for a range of treatment applications. Copyright Kay Elemetrics Corp, Pine Brook, NJ. Reprinted with permission.

Oral prosthetics can offer structural support and compensation to oropharyngeal structures that were lost or altered postsurgery. Palatal lowering prostheses recontour or lower the palate to allow the remaining portion of the resected tongue to contact the palate when swallowing.[47] Obturators can fill a palatal defect, preventing food leakage into the nasal cavity and establishing more normal intraoral pressure. Use of these devices can significantly reduce oral residue. The speech pathologist collaborates with the maxillofacial prosthodontist to provide feedback on the configuration, use, and benefits of the prosthesis.