Post-Chemoradiation of Head and Neck Cancer: SND and Aspiration

Our retrospective review was designed to evaluate the incidence of aspiration among chemoradiated head and neck cancer patients, said Dr. Langerman. We know that the incidence is considered high, especially in the peritreatment period, but data is still emerging about aspiration and its relationship to the primary tumor site, as well as the severity of aspiration, as it may lead to pneumonia with significant morbidity and possible mortality.

Additionally, these patients may lack sufficient laryngeal sensation to detect aspiration, continued Dr. Langerman. The incidence of subclinical or ‘silent’ aspiration may be much higher than clinical aspiration.

Right now, there are no formalized guidelines for post-chemoradiotherapy swallowing assessment, said Dr. Langerman. However, as more data on the effects of primary tumors and chemoradiation on swallowing function have become available, the need for swallowing assessment for some patients has become obvious. The appropriate timing of these assessments is still under investigation.

In this study, the presence of aspiration was quantified as a percentage of the swallowed bolus during the OPMs. An OPM study performed with videofluoroscopic observation of the swallowing reflex is a highly sensitive tool for the detection of aspiration. For the purposes of this study, aspiration (deep laryngeal or tracheal penetration) of 5% or less of the swallowed bolus was considered trace and greater than 5% was considered frank.

In the first year following treatment, 118 patients (91%) had OPMs. Eighty-one patients (69%) had at least one OPM demonstrating aspiration within the first year following chemoradiation, with 30 (25%) demonstrating frank aspiration. Of the patients who aspirated, 61 (75%) reported no symptoms of coughing or choking (80% of trace and 67% of frank aspirators). For the 62 patients with pretreatment OPM data, 33 (53%) demonstrated aspiration at baseline.

The study demonstrated a very high rate of aspiration in advanced-stage head and neck cancer patients both prior to (53%) and in the first year following chemoradiation (69%). The study also concluded that therapeutic swallowing maneuvers taught during OPMs are effective, especially for those patients with trace aspiration, and CRT may improve response to therapy.

In our series, every patient in whom aspiration was identified underwent additional swallows using therapeutic maneuvers designed specifically for their impairment, said Dr. Langerman. For instance, if a patient had poor clearing of food from the laryngeal inlet ultimately leading to aspiration, he may have been taught to swallow twice with each food bolus, helping to clear the food. If this eliminated aspiration, he could be cleared for oral intake of food, with precautions of course. Changing the consistency of the food, such as thickening liquids, can also help some patients not to aspirate.