Arch Otolaryngol Head Neck Surg. Copyright American Medical Association. Validated instruments used to evaluate swallowing included the Penetration-Aspiration Scale and the M. Also, the oropharyngeal chemoradiotherapy group had better self-perceived swallowing ability than the surgery-radiotherapy group on the basis of the M.
Dysphagia, or impairment of swallowing function, Penetration when swallow a frequent consequence of head and neck cancer and its treatment that can result in decreased quality of life and nutritional deficiency.
The treatment of advanced squamous cell carcinoma of the head and neck has evolved over the last decade to include combination chemotherapy and external beam radiotherapy. Comparable survival rates have been achieved with chemoradiotherapy CRT with surgical salvage vs surgery and radiation therapy SRT for multiple head and neck sites. Although the detrimental effects of both SRT and CRT on swallowing have been well documented in a number of case series, 6 - 10 few studies have directly compared the swallowing outcomes of patients who undergo SRT with those who undergo CRT.
This lack of information may in part be a result of a lack of agreement as to which components of swallowing are most highly associated with important patient outcomes, such as airway protection, dietary intake, nutritional status, and quality of life. Given the comparable survival rates of CRT and SRT, information concerning the swallowing consequences of treatment would be helpful to patients and clinicians who must decide between competing treatment strategies.
Evidence suggests that swallowing function after treatment of head and neck cancer reaches a steady state that is representative of long-term outcome at approximately 12 months after therapy. The institutional review board of the Medical University of South Carolina, Charleston, approved the study design and the informed consent process. Eligible subjects were identified and stratified by tumor subsite, T stage, and treatment modality using information available from the cancer registries of the Medical University of South Carolina—Hollings Cancer Center and the Ralph H.
Chemotherapy had to be delivered as a primary modality with curative intent. Patients receiving triple therapy chemotherapy, surgery, and irradiation and patients with neurologic conditions eg, stroke or neurodegenerative disease that would affect swallowing were excluded.
Potential subjects were contacted via telephone to ask them to participate in the study. When a subject agreed to Penetration when swallow, an attempt was made to recruit a subject matched for tumor site and T stage from the other treatment group to maximize balance between treatment groups. A complete head and neck examination with flexible laryngoscopy was performed on all subjects to rule out persistent or recurrent tumor.
Subjects completed the M. Anderson Dysphagia Inventory MDADI14 a validated instrument to assess the effects of Penetration when swallow on swallowing-related quality of life in the head and neck population, and underwent a modified barium swallow MBS under the direction of a speech-language pathologist and radiologist.
MBS protocol consisted of a series of two 5-,and mL swallows of thin liquid barium. The MBS was concluded early if the patient demonstrated evidence of aspiration with decreased airway clearance or if the patient refused to proceed. All results were "Penetration when swallow" with a subject research number only, without the patient information being "Penetration when swallow" on the viewing screen. Two speech-language pathologists M. The PAS score is assigned based on the level of penetration or aspiration and on the patient response to airway contamination during videofluoroscopy.
The mean PAS scores for each volume were calculated and compared between treatment groups. The emotional subscale consists of 6 questions that assess the degree to which the patient is upset or embarrassed by his or her swallowing problem.
The functional subscale includes 5 questions that are designed to assess ease of food preparation and eating in public. The mean of the MDADI subscale scores MDADI total was calculated for each subject to produce a single numerical value that is representative of overall swallowing ability, with a score of indicating no dysphagia and a score of 20 representing severe dysphagia. The PAS scores were between groups using the Wilcoxon rank sum test for ordinal data.
A total of 21 subjects with oropharyngeal cancer entered the study: Comparisons between the 2 groups revealed no significant differences in mean age Penetration when swallow the subjects, sex distribution, and mean time since treatment or oropharyngeal subsite Table 1.
Surgery for oropharyngeal cancer consisted of wide excision with primary closure or skin graft in 7 subjects, wide excision with Penetration when swallow forearm free flap in 3 Penetration when swallow, and wide excision with levator scapula flap in 1 subject. Three of the patients who underwent oropharyngeal surgery had a transoral resection, with the remaining 8 requiring mandibulotomy or pharyngotomy approaches.
Chemotherapy consisted of concomitant CRT with cisplatin and fluorouracil in 7 subjects, cisplatin and paclitaxel in 2 subjects, and cisplatin, fluorouracil, and paclitaxel in 1 subject. Subjects were assessed for the consistency of their present diet compared with their diet at the time of their cancer diagnosis. There was no history of aspiration pneumonia in any study subject.
A total of 20 patients underwent MBS testing under the supervision of a speech-language pathologist. One patient in the CRT oropharyngeal group was unable to participate because of transportation issues. Each subject performed 2 swallows of 5, 10, and 20 mL of thin liquid barium in a progressive fashion, for a total of 6 swallows.
All subjects in the CRT oropharyngeal Penetration when swallow completed the entire MBS examination, whereas 2 patients in the SRT oropharyngeal group were unable to complete the full examination because of repeated aspiration Penetration when swallow could not be cleared with compensatory maneuvers.
The association between the MDADI scores and the PAS scores was investigated to determine whether greater levels of laryngeal penetration and aspiration were associated with a reduction in swallowing-related quality of life. Although laryngeal penetration and aspiration are associated with potentially severe medical consequences eg, aspiration pneumoniathis finding suggests that there may be little association between airway protection during swallowing and swallowing-related quality of life.
Dysphagia, which is a frequent consequence of head and neck cancer and its treatment, may result in poor health and reduced quality of life. The MDADI has been shown to be sensitive and "Penetration when swallow" in regard Penetration when swallow swallowing-related quality-of-life items in the head and neck cancer population.
Penetration when swallow 20 towith representing no dysphagia, the instrument is easy to score and interpret. Therefore, the use of sensitive instruments such as the MDADI may improve our ability to recognize patients with dysphagia. The MBS, which is performed under the supervision of a speech-language pathologist and a radiologist, is the radiographic tool most commonly used for the evaluation and treatment of dysphagia.
It provides visualization of the structural movements of the upper aerodigestive tract during bolus passage 18 and allows the identification and characterization of specific Penetration when swallow in the timing and coordination of swallowing. Also, the speech-language pathologist can institute and evaluate compensatory swallowing strategies in real time during the examination. The clinical utility of the MBS in the evaluation and treatment of dysphagia is supported by a retrospective study of MBS examinations performed on dysphagic patients.
Penetration when swallow the clinical utility of the MBS in the evaluation of dysphagia is well accepted, the relationship of specific MBS findings to specific patient outcomes is less well established. The PAS was introduced in as a way to quantify the presence and degree of airway penetration the bolus enters the vestibule but stays above the glottis and aspiration the bolus passes below the glottis on MBS examination.
On the basis of the PAS, the present study found better airway protection during
Penetration when swallow among patients with oropharyngeal cancer who were treated with CRT than among patients with oropharyngeal cancer who were treated with SRT. Although the study predicted a greater risk of aspiration in the SRT oropharyngeal group, the clinical significance of this finding Penetration when swallow uncertain, because no patient in the study suffered a documented case of aspiration pneumonia.
Also, the PAS only quantifies 1 parameter of swallowing airway protectionwhile failing to quantify other parameters, such as bolus preparation and transportation. This finding may indicate that laryngeal penetration and aspiration have little impact on swallowing-related quality of life. Because subjective symptoms of dysphagia may not correlate with underlying swallowing dysfunction, our head and neck group routinely performs an MBS on all patients with advanced head and neck cancer, preferably before and after therapy, to ensure adequate airway protection and to identify patients who may benefit from further swallowing therapy.
Also, measures of laryngeal penetration and aspiration only look at one aspect of swallowing and therefore fail to capture the overall physiologic functions of swallowing.
Further study is needed to identify parameters of swallowing that are associated with important patient-based outcomes. The assumption that organ preservation translates into functional preservation appears to be true in this small sample of patients with oropharyngeal carcinoma.
These findings lend objective support to head and neck tumor boards that are increasingly recommending concurrent CRT as a first-line treatment for stage III and IV oropharyngeal carcinoma.
Several study limitations, however, deserve mention. A cross-sectional study does not permit an assessment of differences in airway-protection mechanisms and swallowing-related quality of life between groups at baseline.
A multi-institutional, longitudinal study of swallowing in patients with head and neck cancer would be helpful to determine if certain baseline characteristics predict better swallowing with one treatment "Penetration when swallow" opposed to another. Also, the best estimate of functional outcomes requires an intent-to-treat analysis that includes surgical salvage patients within the chemotherapy cohort and adjuvant chemotherapy patients in the surgical cohort. It is Penetration when swallow that surgical and chemotherapeutic salvage results in worse functional outcome than dual-modality therapy alone.
Penetration when swallow, the majority of patients in the CRT group received high-dose cisplatin and fluorouracil and standard radiotherapy therapy instead of the less-toxic low-dose cisplatin and paclitaxel regimen and intensity-modulated radiotherapy that is currently favored at our institution.
Therefore, the functional outcomes of the patients whom we are currently treating may ultimately be vastly different from those of the patients whom we have treated in the past. Dysphagia is a frequent sequela of head and neck cancer and its treatment. Chemoradiotherapy appears to result in better airway protection during swallowing and in better swallowing-related quality of life than SRT for patients with oropharyngeal cancer.
Further characterization of swallowing differences among head and neck cancer treatment groups will require additional research to identify and validate critical
Penetration when swallow of swallowing, other than airway-protection mechanisms, that are reliable and predictive of important patient-based outcomes.
August 31, ; accepted March 22, Accessed August 12, Randomized trial of radiation therapy versus concomitant chemotherapy and radiation therapy for advanced-stage oropharynx carcinoma. Swallowing disorders in head and neck cancer patients treated with radiotherapy and adjuvant chemotherapy.
Objective assessment of swallowing dysfunction and aspiration after radiation concurrent with chemotherapy for head and neck cancer. Advanced oropharyngeal carcinoma treated with surgery and radiotherapy: Speech and swallowing function after oral and oropharyngeal resections: Swallowing and tongue function following treatment for oral and oropharyngeal cancer.
The development and validation of a dysphagia specific quality-of-life questionnaire for patients with head and neck cancer: Concurrent chemotherapy and radiotherapy for organ preservation in advanced laryngeal cancer. Brodsky, MA ; Terry A. Day, MD ; et al Anand K. Back to top Article Information. Sign in to access your subscriptions Sign in to your personal account.
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Tohoku J Exp Med. Jan;(1) The risk of penetration or aspiration during videofluoroscopic examination of swallowing varies depending on food. Dysphagia is the term for swallowing disorders. Penetration is when food or liquid goes into the trachea and stays above the vocal cords. Aspiration.