Difficulty eating and swallowing food—dysphagia—can have a significant impact on a patient’s life after radiation treatment and surgery. Consuming enough nutrition is critical to a your ability to recover from surgery and tolerate life saving treatments. Recognizing this disorder early allows you and your doctor to implement an effective treatment plan. In the long term, patients may experience some permanent eating and swallowing disability as a result of treatment, but in many cases this can be treated or compensated for.

“Oropharyngeal dysphagia is a swallowing problem that happens before food reaches the esophagus and may result from neuromuscular disease or obstructions. Patients experience difficulty starting a swallow, food goes down the wrong pipe, or there is choking and coughing. This may result in poor nutrition or dehydration, aspiration (accidentally sucking food into the lungs during swallowing, which can lead to pneumonia and chronic lung disease) or embarrassment in social situations that involve eating…”

Dysphagia Definition

Signs and symptoms associated with dysphagia may include:

  • Having pain while swallowing (odynophagia)
  • Being unable to swallow
  • Having the sensation of food getting stuck in your throat or chest or behind your breastbone (sternum)
  • Drooling
  • Being hoarse
  • Bringing food back up (regurgitation)
  • Having frequent heartburn
  • Having food or stomach acid back up into your throat
  • Unexpectedly losing weight
  • Coughing or gagging when swallowing
  • Having to cut food into smaller pieces or avoiding certain foods because of trouble swallowing

The following information is heavily drawn from an original CE course  written by Joy E. Gaziano, MA, CCC-SLP.  For the original version of the article

Evaluation and Management of Oropharyngeal Dysphagia in Head and Neck Cancer

Introduction

Dysphagia, derived from the Greek phagein, meaning “to eat,” is a common symptom of head and neck cancer and can be an unfortunate sequelae of its treatment. Dysphagia is any disruption in the swallowing process during bolus transport from the oral cavity to the stomach. In head and neck cancer patients, dysphagia may be caused by surgical ablation of muscular, September/October 2002, Vol. 9, No. 5 Cancer Control 401 bony, cartilaginous, or nervous structures or may be attributable to the effects of antineoplastic agents including radiation and/or chemotherapy. The severity of the swallowing deficit is dependent on the size and location of the lesion, the degree and extent of surgical resection, the nature of reconstruction, or the side effects of medical treatments. Evaluation and treatment of swallowing disorders present unique challenges to the speech pathologist working with the head and neck cancer population. Successful management requires interdisciplinary collaboration, accurate diagnostic workup, effective therapeutic strategies, and consideration for unique patient characteristics.

Normal Swallowing Function

Swallowing is a complex series of sequential neuromuscular events that are integrated into a smooth and continuous process. To appreciate the potentially devastating effects of oral cancer on swallowing, it is helpful to understand normal anatomy and physiology. Generally, the process is divided into three stages: oral, pharyngeal, and esophageal.

The oral phase is completely voluntary and involves the entry of food into the oral cavity and preparation for swallowing; this includes mixing with saliva, mastication, and formation into a cohesive bolus in preparation for the swallow. It requires coordination of the lips, tongue, teeth, mandible, and soft palate. The pharyngeal phase is initiated as the tongue propels the bolus posteriorly and the base of tongue contacts the posterior pharyngeal wall, eliciting a reflexive action that begins a complex series of events. The soft palate elevates to prevent nasal reflux. The pharyngeal constrictor musculature contracts to push the bolus through the pharynx. The epiglottis inverts to cover the larynx and prevent aspiration of contents into the airway. The vocal folds adduct to further prevent aspiration. The hyolaryngeal complex moves anteriorly and superiorly, which, in combination with the pressure generated by a bolus, provides anterior traction and intrabolus pressure to open the cricopharyngeus. The esophageal phase is completely involuntary and consists of peristaltic waves that propel the bolus to the stomach. Total swallow time from oral cavity to stomach is no more than 20 seconds.

Cranial nerve function is often interrupted in surgical resection of head and neck tumors. Swallowing deficits may result when any one or more of five cranial nerves are affected. The trigeminal nerve (CN V) controls general sensation to the face and motor supply to the muscles of mastication. The facial nerve (CN VII) controls taste to the anterior two thirds of the tongue and motor function to the lips. The glossopharyngeal nerve (CN IX) provides general sensation to the posterior third of the tongue and motor function to the pharyngeal constrictors. The vagus nerve (CN X) provides general sensation to the larynx and motor function to the soft palate, pharynx, larynx, and esophagus. The hypoglossal nerve (CN XII) controls motor supply to the intrinsic and extrinsic muscles of the tongue.

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. Cervical auscultation uses a stethoscope on the larynx to detect the sounds of swallowing and respiration. 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 video fluoroscopic assessment of swallowing. 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