Dysphagia after sequential chemoradiation therapy for advanced head and neck cancer.
ABSTRACT Assess impact of sequential chemoradiation therapy (SCRT) for advanced head and neck cancer (HNCA) on swallowing, nutrition, and quality of life.
Prospective cohort study of 59 patients undergoing SCRT for advanced head and neck cancer. Follow-up median was 47.5 months.
Regional Cancer Center.
Median time to gastrostomy tube removal was 21 weeks. Eighteen of 23 patients who underwent modified barium swallow demonstrated aspiration; none developed pneumonia. Six of 7 with pharyngoesophageal stricture underwent successful dilatation. Functional Assessment of Cancer Therapy-Head and Neck Scale questionnaires at median 6 months after treatment revealed "somewhat" satisfaction with swallowing. At the time of analysis, 97% have the gastronomy tube removed and take soft/regular diet.
Early after treatment dysphagia adversely affected weight, modified barium swallow results, and quality of life. Diligent swallow therapy, and dilation as needed, allowed nearly all patients to have their gastronomy tubes removed and return to a soft/regular diet.
Dysphagia is significant after SCRT but generally slowly recovers 6 to 12 months after SCRT.
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ABSTRACT: Background and purpose To evaluate the course of health-related quality of life (HRQOL) from diagnosis to 2 years follow-up in patients with head and neck cancer (HNSCC) treated with chemoradiation (CRT). Materials and methods 164 patients completed the EORTC QLQ-C30 and QLQ-H&N35 questionnaires 1 week before and 6 weeks and 6, 12, 18, and 24 months after CRT. Patients were compared to a reference group. A linear mixed-model analysis was used to assess changes in HRQOL over time, and whether this was associated with age, gender, comorbidity, and tumor sublocation. Results Significant differences for the majority of HRQOL scales were observed between patient and reference group at baseline, and follow-up. The course of HRQOL was different for survivors compared to non-survivors. In survivors, improvement over time was observed (in global quality of life, physical, role, and social function, fatigue, pain, swallowing, speech, social eating, and social contacts), while in non-survivors the pattern over time was either no changes in HRQOL or a deterioration (in physical function, social eating and contacts). In both survivors and non-survivors, emotional functioning improved after treatment, but deteriorated in the longer term. Patients with comorbidity reported worse physical function, and patients with oral/oropharyngeal cancer (compared to hypopharyngeal/laryngeal cancer) reported more oral pain and sexual problems, but fewer speech problems. Conclusions The course of HRQOL of HNSCC patients during the first 2 years after CRT is different for survivors compared to non-survivors and is associated with comorbidity and tumor subsite.Radiotherapy and Oncology 01/2014; · 4.52 Impact Factor
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ABSTRACT: Selecting patients with head and neck cancer requiring a pre-treatment gastrostomy feeding tube is not straightforward. The nutritional status and functional deficits associated with the cancer, its treatment and long term side effects predicate the need for gastrostomy tube placement. However gastrostomy tubes are not without morbidity and are an added burden to the patient. Aim of this retrospective case series review was to evaluate the clinical characteristics of new H&N cancer patients treated with curative intent having gastrostomy placement with the intent of developing a protocol to help the timely selection of patients for pre-treatment gastrostomy insertion. A gastrostomy tube was placed in 32%. A regression model identified five independent predictors (p<0.001) to predict gastrostomy tube: overall clinical stage, tumour site, clinical T stage, patient age, and clinical N stage. A protocol to help the multi-disciplinary team (MDT) decision whether a pre-treatment gastrostomy tube should be placed is suggested.Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology 01/2014; · 1.50 Impact Factor
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ABSTRACT: The accurate definition of organs at risk (OARs) is required to fully exploit the benefits of intensity-modulated radiotherapy (IMRT) for head and neck cancer. However, manual delineation is time-consuming and there is considerable inter-observer variability. This is pertinent as function-sparing and adaptive IMRT have increased the number and frequency of delineation of OARs. We evaluated accuracy and potential time-saving of Smart Probabilistic Image Contouring Engine (SPICE) automatic segmentation to define OARs for salivary-, swallowing- and cochlea-sparing IMRT.Radiation oncology (London, England). 08/2014; 9(1):173.
Dysphagia after sequential chemoradiation therapy
for advanced head and neck cancer
Laura A. Goguen, MD, Marshall R. Posner, MD, Charles M. Norris, MD,
Roy B. Tishler, MD, PhD, Lori J. Wirth, MD, Donald J. Annino, MD, DMD,
Adele Gagne, MS, CC/SLP, Christopher A. Sullivan, MD,
Daniel E. Sammartino, and Robert I. Haddad, MD, Boston, Massachusetts; and
Winston-Salem, North Carolina
therapy (SCRT) for advanced head and neck cancer (HNCA) on
swallowing, nutrition, and quality of life.
Prospective cohort study of 59 patients un-
dergoing SCRT for advanced head and neck cancer. Follow-up
median was 47.5 months.
Regional Cancer Center.
Median time to gastrostomy tube removal was 21
weeks. Eighteen of 23 patients who underwent modified barium
swallow demonstrated aspiration; none developed pneumonia.
Six of 7 with pharyngoesophageal stricture underwent success-
ful dilatation. Functional Assessment of Cancer Therapy–Head
and Neck Scale questionnaires at median 6 months after treat-
ment revealed “somewhat” satisfaction with swallowing. At the
time of analysis, 97% have the gastronomy tube removed and
take soft/regular diet.
Early after treatment dysphagia adversely af-
fected weight, modified barium swallow results, and quality of life.
Diligent swallow therapy, and dilation as needed, allowed nearly
all patients to have their gastronomy tubes removed and return to
a soft/regular diet.
Dysphagia is significant after SCRT but gen-
erally slowly recovers 6 to 12 months after SCRT.
EBM rating: C-4
© 2006 American Academy of Otolaryngology–Head and Neck
Surgery Foundation. All rights reserved.
Assess impact of sequential chemoradiation
has proven successful at improving locoregional control,
progression free survival, and overall survival.1 A primary
aim of organ preservation therapy is retention of vital tissue
and thereby maintenance of normal breathing, swallowing,
and communicating functions. When reviewing different treat-
treatment-related side effects and their impact on quality of life
(QOL). As more patients receive CRT and survive, there must
be increased attention focused on the long-term treatment side
effects: xerostomia, dysphagia, and depression.2
Dysphagia occurs in up to 50% of patients after CRT.2
Acute toxicities including mucositis, pain, nausea, and de-
creased appetite can temporarily lessen the ability to take
nutrition by mouth. Late complications, such as xerostomia
and fibrosis, can result in long-term swallowing problems.
Patients are often further troubled by copious thick secretions,
edema, and diminished pharyngeal sensation. The nutritional
and dietary limitations caused by dysphagia can furthermore
result in poor general health and poor overall QOL.
This study seeks to characterize swallow function before
and after CRT for advanced head and neck cancer (HNCA)
and to understand its impact on nutrition and QOL. Several
measures were used including patient symptoms, weight,
timing of gastronomy tube (GT) removal, diet, modified
barium swallow (MBS) results, and QOL assessments. Pa-
ncreasingly head and neck cancer is being managed with
intensive chemoradiation therapy (CRT). This treatment
From the Departments of Surgery/Division of Otolaryngology (Drs
Goguen, Norris, Annino, and Sullivan); Medical Oncology (Drs Posner,
Wirth, and Haddad, and Mr Sammartino); Radiation Oncology (Dr Tishler);
and Speech and Swallowing (Ms Gagne); at the Brigham and Women’s
Hospital and the Dana Farber Cancer Institute, Boston. Dr Sullivan is
currently at the Department of Otolaryngology, Wake Forest University
Health Sciences, Winston-Salem, North Carolina.
Reprint requests: Laura A. Goguen, MD, Division of Otolaryngology, The
Brigham and Women’s Hospital, 45 Francis Street, Boston, MA 02115.
E-mail address: firstname.lastname@example.org.
Otolaryngology–Head and Neck Surgery (2006) 134, 916-922
0194-5998/$32.00 © 2006 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.
tients were assessed before treatment, immediately after
treatment, and at regular intervals up to a mature follow-up
of median 47.5 ? months.
MATERIALS AND METHODS
Seventy-two patients with advanced stage III or IV HNCA
without distant metastases began protocol-based sequential
chemoradiation therapy (SCRT) between June 1999 and
December 2002.3 All patients had squamous cell carcinoma
of the head and neck. Unknown primaries and primary
cancer sites in the sinonasal cavity, nasopharynx, and sali-
vary glands were excluded. Thirteen patients were not in-
cluded in this analysis: 1 had unacceptable toxicity after the
first cycle of induction chemotherapy and went off study; 3
patients quit treatment during induction chemotherapy; 2
patients developed progressive disease during treatment and
went off protocol; 7 patients developed early recurrent dis-
ease between 2 and 12 weeks after completion of chemo-
radiation therapy and died between 2 weeks and 8 months
after treatment. Six of 7 of these patients died with their
GTs. This report analyzes the remaining 59 patients.
No patient had a history of neurologic disease, gastroen-
terologic dysfunction, previous head and neck cancer, or
prior surgical or radiation treatment to the head and neck.
SCRT consisted of 3 cycles of platinum-based induction
chemotherapy (IC), followed by concurrent CRT with once
daily radiation therapy and weekly carboplatin at an AUC of
1.5.3 The IC regimen was cisplatin, 5-Fluorouracil with or
without docetaxel given for 3 cycles every 21 days. The
total dose of radiation to the primary was 70 to 74 Gy.
Involved nodal regions received at least 60 Gy, uninvolved
nodal regions at least 50 Gy. Radiation was delivered at a
dose of 2 Gy per day. Neck dissections were planned be-
tween 6 and 12 weeks after CRT. Neck dissection was
advised for those patients without a neck complete clinical
response to induction chemotherapy or initial N3 disease.
Twenty-three patients underwent neck dissection.
Gastrostomy tube placement was performed after induc-
tion chemotherapy. Ongoing oral intake was encouraged as
tolerated. Throughout treatment the patients were followed
by the nutrition service. Patients with increased or pro-
tracted dysphagia after treatment underwent MBS and swal-
Swallow function was assessed both before and after
treatment. Pretreatment assessments included: the patients’
subjective sense of their swallowing ability, The Functional
Assessment of Cancer Therapy–Head and Neck Scale
(FACT–H&N),4 and pretreatment weight loss. The highest
grade of mucositis during treatment was determined using
the RTOG/EORTC Acute Radiation Morbidity Criteria,
grades 0 to 4.5 Post-treatment assessments included: weight
loss, diet, time to GT removal, MBS with Swallow Perfor-
mance Status6 applied, and FACT H&N QOL survey.
The FACT–H&N is a validated, self-reported QOL in-
strument.7 We additionally focused on target questions re-
lated to swallowing (questions 1, 5, 7, 11). Use of this
symptom specific index has not been validated. We hypoth-
esized that diet and time to GT removal would correlate
well with swallow related QOL. The questionnaire was
administered before treatment, after induction chemother-
apy cycle 2 and 3, and 6 to 9 months after treatment.
The MBS studies were conducted at Brigham and Women’s
Hospital in accordance with the routine radiographic proto-
cols approved by the institution and were performed jointly
by the radiologist and speech pathologist. Subjects swal-
lowed liquid barium, barium paste, and a barium-coated
cookie. All participants completed the study positioned upright
and viewed in the lateral plane. The oral preparatory, oral,
pharyngeal, and cervical esophageal phases were assessed.
The incidence of laryngeal penetration, defined as entry of
the bolus into the laryngeal vestibule above the vocal cords,
and aspiration, defined as bolus passing below the vocal
folds, were recorded. Patients were given advice with re-
spect to a safe diet, appropriate helpful swallow maneuvers,
and the need for further swallow therapy.
Follow-up period, overall survival (OS), and progression-
free survival (PFS) were calculated from the date of treat-
ment initiation. Patients were examined weekly during
treatment. Patients were evaluated with physical examina-
tion and appropriate imaging monthly during the first year,
every other month in the second year, and every 3 to 6
As shown in Table 1, the median patient age was 54 years,
(range, 38 to 75). Sixteen patients were female and 43 were
male. Primary tumor locations were oral cavity 3, orophar-
ynx 42, larynx 11, and hypopharynx 3. The primary and nodal
stages are outlined in Table 1. Overall stages were stage III 8,
to 74.5 months; median was 47.5 months.
Airway compromise required 2 patients to undergo a
tracheotomy before treatment and 3 after treatment. Three
patients had recurrent disease at the primary site and under-
went salvage surgery. One patient underwent total laryngec-
tomy due to chondroradionecrosis of the larynx.
At the time of analysis, 81% are disease-free and 90%
are survivors. The median overall survival is 45.3? months.
The median progression free survival is 43.5? months.
Pretreatment Swallow Assessments
Before treatment, 41% of patients described dysphagia or
odynophagia and 59% denied any swallowing difficulties.
FACT H&N questionnaire findings are reported in Table 2.
The mean pretreatment score for the questions pertaining to
swallowing function was 3.2 (scale, 0 to 4). This indicated
“quite a bit” of satisfaction with swallowing and diet.
917 Goguen et alDysphagia after sequential chemoradiation . . .
Documentation of pretreatment weight loss was avail-
able for 35 of the 59 patients; 20 reported no weight loss.
The range of reported weight loss was 0 to 27 kg; mean
4 kg, median 0 kg.
The highest grade of mucositis during treatment was
determined. The mean highest grade was 2.6 (scale, 0 to 4).
Grade 2 or 3 mucositis was identified in 55 (93%) of 59
Post-treatment Swallow Assessments
The median weight loss after completion of CRT was 9.6 kg
with a range of 3.6 kg gain to 29.7 kg loss. The median
percent weight loss was 12.7% with a range of 7.5% gain to
GT dependence and diet after completion of chemora-
diation therapy was assessed with findings as noted in Fig-
ure 1. At 3, 6, 9, and 12 months, 17%, 53%, 70%, and 80%
of patients took a soft or regular diet, respectively. At the
time of analysis, 97% of patients are taking a soft or regular
The median time to GT removal after CRT was 21 weeks
with a range of 1 week to 218 weeks. At 3, 6, 9, 12 months,
and 2 years, the GT was removed in 27%, 63%, 80%, 81%,
and 90% of patients, respectively. As noted, 9% had their
GTs removed between 1 and 2 years after treatment. Two
(3%) of 59 patients still have their GTs at 140 and 112
weeks. One patient has recurrent disease at his primary site
and has been receiving palliative chemotherapy. The other
patient takes a nutritionally adequate soft diet by mouth but
prefers to keep his GT.
Twenty-three patients underwent a MBS (Table 3.) after
chemoradiation therapy. The decision to perform MBS was
based on patient or clinician appreciated swallowing diffi-
culties beyond that expected after treatment. The studies
were performed between 1 week and 13.5 months after treat-
ment, median, 3.5 months. At the time the patients underwent
MBS, 7 had their GTs removed and were taking oral diets: 1
pureed, 2 soft, 4 regular. Pharyngeal phase problems were
most commonly noted, including in order of frequency:
decreased epiglottic movement, decreased base of tongue
contact to posterior oropharyngeal wall, decreased laryngeal
elevation, and decreased bolus propulsion.
Penetration without aspiration was identified in 4 pa-
tients and 18 patients had aspiration. Aspiration was silent
in 8. The advised diets for these 8 patients were: 1 NPO, 1
thickened liquids, 1 pureed, 3 modified diet, and 2 regular.
Swallow therapy was undertaken by all of these patients. No
patient developed aspiration pneumonia.
GT removal required special management in several pa-
tients. MBS revealed that 14 patients had pharyngoesopha-
geal narrowing, usually located between the hypopharyneal
and the cervical esophageal regions; 7 required pharyngoe-
sophageal dilation. One patient had esophageal stenosis
after salvage laryngectomy and regional flap reconstruction.
Dilations were performed between 1 and 14 times per pa-
tient, median 2 times. After dilations, 6 of the 7 patients
were able to have their GTs removed. Five patients take a
regular diet. One patient takes a soft diet. The one remaining
patient with a GT takes a nutritionally adequate soft diet but
feels more secure with his GT in place. Continued utiliza-
tion of swallow therapy and dilations as needed provided
reduction of overall GT dependence in this population to
3% of patients.
The Swallow Performance Scale (SPS)6 was applied to
the MBS results. The mean score was grade 5 (scale, 1 to 7),
indicating moderate swallow dysfunction. SPS results are
further displayed in Table 3.
The FACT H&N QOL questionnaire was administered
after treatment. Twenty-six of 59 patients answered the ques-
tionnaire within 5.5 to 9.5 months, median 6 months, with
findings as noted in Table 2. At the time the patients re-
sponded to the questionnaire, 16 (62%) had their GTs re-
moved and were taking oral diets: 13 regular, 2 soft, and 1
pureed. The overall mean score for the swallowing-related
questions was 2.0, indicating “somewhat” satisfaction with
swallowing and diet. The lowest score was for question 7
“I can swallow naturally and easily.” The mean response
was 1.35, indicating “a little bit” of agreement with the
Patient characteristics, n ? 59
Progression free survival*
21.5-74.5 ? months
47.5 ? months
43.5 ? months
45.3 ? months
*Follow-up duration, progression free survival, and overall
survival calculated from start of treatment.
918Otolaryngology–Head and Neck Surgery, Vol 134, No 6, June 2006
As chemoradiotherapy becomes more widely used for treat-
ment of HNCA it is imperative to appreciate, prevent, and
optimally manage treatment-related side effects. The aim of
this study was to understand the frequency and severity of
dysphagia in patients undergoing CRT for advanced HNCA
and its impact on nutrition and QOL. During and after
treatment, dysphagia adversely affected weight, need for
GT, diet, MBS, and QOL survey results. Longer term fol-
low-up demonstrated that nearly all patients had their GTs
removed and returned to a soft or regular diet. Further
analysis revealed that perseverance with swallow rehabili-
tation is needed to provide this level of functional organ
preservation. Notably 12% of patients required pharyngoe-
sophageal dilations and 9% of patients had their GTs re-
moved between 1 to 2 years after treatment.
Dysphagia assessment begins with an initial determina-
tion of the tumor’s influence on swallowing. Though 41% of
the patients reported swallowing difficulties before treat-
ment, the median reported pretreatment weight loss was
0 kg, and FACT H&N QOL responses indicated patients
were “quite a lot” satisfied with their swallowing.
Gastrostomy tubes were placed before chemoradiation
therapy in anticipation of evolving treatment-related swal-
lowing difficulties. This approach helps insure that patients
finish treatment on time without delays related to admission
for hydration or GT placement. An imperative part of “up-
front” GT placement is ongoing encouragement of oral
intake to avoid unnecessary and early GT dependence. Dur-
ing follow-up visits with the physician team, nutrition ser-
vice, and swallow therapists, the patients were coached and
strongly advised to continue oral intake as long as possible
Treatment resulted in significant weight loss and swal-
lowing difficulties. The median weight loss was 9.6 kg or
12.7%. However, within a year after treatment and at the
time of this analysis, nearly all patients were able to return
Diet after chemoradiation therapy.
Quality of life assessment, FACT-HN
Variable Before CRTAfter CRT (median 6 months)
1. I am able to eat the foods I like.
5. I am able to eat as much food as I want.
7. I can swallow naturally and easily
11. I can eat solid foods
Mean response swallow questions
Total swallow questions
FACT-H&N subscale score
Total FACT-H&N score (H&N ? G)
n ? 58n ? 25
*Questionnaire asks subjects to indicate how true each statement is: 0, not at all; 1, a little bit; 2, somewhat; 3, quite a bit; 4, very
919Goguen et alDysphagia after sequential chemoradiation . . .
to a regular or soft diet and have their GTs removed. The
median time to GT removal was 21 weeks, 10% were GT
dependent at 2 years, and only 2 of 59 patients still have
their GTs. A regular or soft diet was taken by 80% at 1 year
and 97% at the time of this analysis. Others have reported
longer rates of GT dependence. Nguyen et al8 assessed
dysphagia in 55 patients after concurrent CRT with median
follow-up of 17 months. They reported a median weight loss
of 8 kg and a median time to GT removal of 9 months.
Staar9 and Ang10 reported considerably higher rates of GT
dependence among survivors at 2 years after treatment, 30%
and 29%, respectively. Differences in length of GT depen-
dence between our report and others may reflect earlier
recognition and aggressive management of dysphagia and
implementation of swallow rehabilitation by a unified team,
in a single institution.
Modified barium swallow is an accepted tool for objec-
tive assessment of swallowing. Our MBS findings were
similar to those reported by others.2,11-13 After chemoradia-
tion therapy swallowing efficiency is decreased and airway
protection is often compromised.
The Swallow Performance Scale (SPS),6 with a score
range of grade 1, normal swallow, to grade 7, severe dys-
phagia, was applied to the MBS results on our patients. The
mean score was grade 5, which indicates moderate swallow
dysfunction. Other investigators have found similar results.
Nguyen et al8 applied the SPS to 33 patients that underwent
MBS for dysphagia after CRT and found 55% had grades 3
to 5, mild to moderate dysphagia. Carrara-de Angelis et al12
applied the O’Neil Dysphagia Outcome and Severity Scale
to 14 patients that prospectively underwent MBS, mean 4.7
months after CRT, and identified mild to moderate dyspha-
gia in 64%.
Aspiration has commonly been identified in MBS per-
formed after CRT with varying degrees of impact on health.
The aspiration is often silent, without an induced cough. When
analyzed prospectively with MBS, the reported incidence of
aspiration has varied widely: Carrara-de Angelis et al 28%,12
Kotz et al 33%,11 Eisbruch et al 68%.13 Carrara-de Angelis et
al12 found that no patients with aspiration on MBS developed
aspiration pneumonia. Gillespie et al14 assessed patients more
than 12 months after CRT with MBS and applied the Penetra-
tion Aspiration Scale (PAS). Even among the patients with
high PAS scores, none developed aspiration pneumonia. In
contrast, Eisbruch et al13 assessed patients at median 2.5
months after CRT and found 5 (29%) of 17 with aspiration
on MBS developed aspiration pneumonia and 2 of 5 died
from their pneumonia. Nguyen et al8 assessed patients with
protracted dysphagia during and after CRT and found that
12 (36%) of 33 patients had silent aspiration. Eight patients
developed aspiration pneumonia and 5 died; 2 died during
treatment and 3 after treatment. Twenty-three of our patients
had protracted or severe dysphagia and underwent post-
treatment MBS. Eighteen (78%) had aspiration on MBS and
silent aspiration was seen in 8 (35%) of 23 cases. However,
none developed aspiration pneumonia. All patients with
aspiration underwent swallow therapy and had their diets
adjusted accordingly, and only 1 patient was advised to
remain NPO. The vast differences in rates of aspiration and
pneumonia may in part be attributable to underlying medi-
cal comorbidities that result in exclusions from protocol-
based reports and some MBS studies that were performed
later after CRT.
Modified barium swallows are not always obtained after
CRT and aspiration is likely under appreciated. Similarly,
the incidence of aspiration pneumonia may be under esti-
mated. Reports by Eisbruch et al13 and Ngyuen8 demon-
strate that aspiration pneumonia can be life threatening but
our patient series and others12,14 show that some patients
with MBS documented aspiration can be managed effec-
tively with swallow therapy and dietary modifications.
There is a need to better differentiate those patients with
aspiration that should remain on enteral feedings only to
help prevent aspiration pneumonia from those patients able
to be managed with maintenance of some oral intake and
thereby facilitate swallow rehabilitation.
The importance of post-treatment MBS with inclusion
of the esophageal phase is underscored by the frequent
identification of pharyngoesophageal strictures in our series
and the need for pharyngoesophageal dilation in 12% of
patients. Pharyngoesophageal stenosis is a potentially treat-
able cause for dysphagia. Subsequent to pharyngoesopha-
geal dilation 6 of 7 patients were able to undergo GT
removal and all 6 take a regular or soft diet. Among patients
Modified barium swallow results, median 3.5 months after chemoradiation therapy, n ? 23
Swallow Performance Scale Grade 1, Normal ? 0
Grade 2, Functional ? 2
Grade 3, Mild impairment ? 3
Grade 4, Mild-moderate impairment ? 1
Grade 5, Moderate impairment ? 11
Grade 6, Moderate-severe impairment ? 4
Grade 7, Severe impairment ? 2
Silent ? 8
Esophageal dilation ? 7
Aspiration, n ? 18
Esophageal Stenosis, n ? 14
Aspiration Pneumonia ? 0
GT removed ? 13
920Otolaryngology–Head and Neck Surgery, Vol 134, No 6, June 2006