Perhaps the most troubling finding of the study was the number of patients with aspiration on their OPMs who reported no symptoms of aspiration. This occurred both before and after chemoradiation, said Dr. Langerman. This highlights the importance of routine swallowing assessment in head and neck cancer patients, to detect subclinical aspiration and to institute therapeutic maneuvers and swallow precautions, as well as to determine the safety of oral feeding.
Explore This Issue
October 2007History alone cannot rule out aspiration in the post-chemoradiation period (or even at baseline). It may be that aspiration risk follows a predictable post-treatment time course and the need for swallowing assessment may diminish over time; however, it is known that swallowing dysfunction is still present even a year following chemoradiation.10
However, many patients do report symptoms of aspiration, such as coughing or choking, while eating or suctioning food from their tracheostoma, said Dr. Langerman. Almost always, at presentation these patients were continuing to eat despite the signs. Some continued because they were unaware of the significance of these findings and the dangers of aspiration, others because they simply wanted to continue eating food at any cost. In the former, the physician’s role is education, prior to initiation of oral feeding. The latter group of patients can be a challenge to convince to stay NPO.
Every ENT who cares for cancer patients should ask about symptoms of aspiration and educate their patients about its dangers, said Dr. Langerman. However, the absence of clinical symptoms cannot rule out aspiration in advanced head and neck cancer patients, particularly in the peri-chemoradiation period. At our institution, all patients undergo routine functional swallowing assessment at baseline and following medical or surgical treatment; those with swallowing abnormalities are taught therapeutic maneuvers during the same exam with the goal of safe oral feeding.
References
- Stenson KM, Huo D, Blair E, et al. Planned post-chemoradiation neck dissection: significance of radiation dose. Laryngoscope 2006;116(1):33-6.
- Pellitteri PK, Robbins KT, Neuman T. Expanded application of selective neck dissection with regard to nodal status. Head Neck 1997;19(4):260-5.
- Andersen PE, Warren F, Spiro J, et al. Results of selective neck dissection in management of the node-positive neck. Arch Otolaryngol Head Neck Surg 2002;128(10):1180-4.
- Chepeha DB, Hoff PT, Taylor RJ, et al. Selective neck dissection for the treatment of neck metastasis from squamous cell carcinoma of the head and neck. Laryngoscope 2002;112(3):434-8.
- Boyd TS, Harari PM, Tannehill SP, et al. Planned postradiotherapy neck dissection in patients with advanced head and neck cancer. Head Neck 1998;20(2):132-7.
- Doweck I, Robbins KT, Mendenhall WM, et al. Neck level-specific nodal metastases in oropharyngeal cancer: is there a role for selective neck dissection after definitive radiation therapy? Head Neck 2003;25(11):960-7.
- Clayman GL, Johnson CJ, 2nd, Morrison W, et al. The role of neck dissection after chemoradiotherapy for oropharyngeal cancer with advanced nodal disease. Arch Otolaryngol Head Neck Surg 2001;127(2):135-9.
- Narayan K, Crane CH, Kleid S, et al. Planned neck dissection as an adjunct to the management of patients with advanced neck disease treated with definitive radiotherapy: for some or for all? Head Neck 1999;21(7):606-13.
- Gupta T, Agarwal JP. Planned neck dissection following chemo-radiotherapy in advanced HNSCC. Int Semin Surg Oncol 2004;1(1):6.
- Pauloski BR, Rademaker AW, Logemann JA, et al. Relationship between swallow motility disorders on videofluorography and oral intake in patients treated for head and neck cancer with radiotherapy with or without chemotherapy. Head Neck 2006;28:1069-76.
©2007 The Triological Society
Leave a Reply