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REVIEW ARTICLE
Dysphagia in Head and Neck Cancer Patients Treated
with Chemoradiotherapy
Nele Platteaux
Æ
Piet Dirix
Æ
Eddy Dejaeger
Æ
Sandra Nuyts
Received: 22 April 2009 / Accepted: 31 July 2009 / Published online: 27 August 2009
ÓSpringer Science+Business Media, LLC 2009
Abstract Dysphagia is a very common complaint of head
and neck cancer patients and can exist before, during, and
after chemoradiotherapy. It leads to nutritional deficiency,
weight loss, and prolonged unnatural feeding and also has a
major potential risk for aspiration. This has a significant
negative impact on the patient’s entire quality of life.
Because treatment of dysphagia in this setting is rarely
effective, prevention is paramount. Several strategies have
been developed to reduce dysphagia. These include swal-
lowing exercises, treatment modification techniques such as
intensity-modulated radiotherapy, selective delineation of
elective nodes, reducing xerostomia by parotid-sparing
radiotherapy, and adding of radioprotectors. However, more
research is needed to further decrease the incidence of
dysphagia and improve quality of life.
Keywords Radiotherapy Head and neck cancer
Dysphagia Intensity-modulated radiotherapy
Deglutition Deglutition disorders
Introduction
Head and neck cancer (HNC) is the sixth most common
malignancy worldwide, representing about 6% of all tumors
and accounting for an estimated 650,000 new cases and
350,000 deaths every year [1]. Radiotherapy (RT) and
surgery are the main treatment modalities, although there is
an increasing role for chemotherapy. The choice of
modality depends on patient factors, primary site, clinical
stage, and resectability of the tumor. Approximately 30-
40% of patients present with early-stage disease, which is
treated by surgery or primary radiotherapy. Around 60% of
patients are diagnosed with a locally advanced stage, which
is associated with a poor prognosis [1]. Standard treatment
for locally advanced HNC has been surgery followed by
postoperative RT. Several trials focusing on organ preser-
vation showed a similar outcome for these patients using
chemoradiotherapy (CRT) [2–4]. Therefore, concurrent
radiation therapy with chemotherapy is nowadays accepted
as an organ-preserving approach [4–7].
Primary radiotherapy for HNC is conventionally given to
a total dose of 70 Gy in once daily fractions of 2 Gy, 5
fractions a week, over 7 weeks [1]. Altered (hyperfraction-
ation and/or acceleration) fractionation schedules and the
use of concomitant chemotherapy have both been tested and
proven to improve locoregional control and overall survival
[5–11]. However, these intensified schedules come at the
cost of more acute and chronic side effects [1,6,7,9]. The
most common acute side effects of CRT for HNC are mu-
cositis, pain, dermatitis, xerostomia, loss of taste, hoarse-
ness, weight loss, myelosuppression, nausea, and dysphagia.
The most frequent late side effects are xerostomia, loss of
taste, fibrosis, trismus, and dysphagia.
Dysphagia is a common, multifactorial, and potentially
life-threatening side effect of CRT, with a potential for
aspiration and death due to aspiration pneumonia [12–14].
It also results in nutritional deficiency leading to weight
loss and the need for prolonged feeding by a percutaneous
endoscopic gastrostomy (PEG) tube. This has a significant
negative impact on the global quality of life (QOL) of
N. Platteaux (&)P. Dirix S. Nuyts
Department of Radiation Oncology, Leuven Cancer Institute,
University Hospitals Leuven, Campus Gasthuisberg, Herestraat
49, 3000 Leuven, Belgium
e-mail: nele.platteaux@uz.kuleuven.ac.be
E. Dejaeger
Department of Geriatrics, Leuven Cancer Institute, University
Hospitals Leuven, Campus Gasthuisberg, Leuven, Belgium
123
Dysphagia (2010) 25:139–152
DOI 10.1007/s00455-009-9247-7
potentially cured patients, causing anxiety and depression
[13,15]. This article focuses on the incidence of dysphagia
in HNC patients treated with CRT and provides an over-
view of methods to prevent this important side effect.
Physiology of Swallowing and Pathophysiology
Normal swallowing is a complex process in which a large
number of cranial nerves and muscles are involved in
carrying food from the mouth through the pharynx into the
esophagus and stomach. Swallowing consists of three
phases [oral (oral preparatory), pharyngeal, and esopha-
geal], with the voluntary oral preparatory and oral phases
followed by an involuntary reflex that must be triggered.
This process implies a rapid and precise coordination
between sensory input and motor function [16–18].
Swallowing involves controlling the food in the mouth,
largely with the oral part of the tongue, to enable tasting and
chewing to occur. The oral tongue moves the food onto the
teeth to crush the food, collects the food from around the
mouth after chewing, brings it together to form a bolus, and
propels it backward out of the mouth. Thereafter, the pha-
ryngeal stage of swallowing is triggered and a number of
necessary motor activities occur: (1) hyoid movement, (2)
closure of the entrance to the nose, the velopharyngeal port,
by elevation of the soft palate to prevent food from entering
the nose, (3) closure of the airway to prevent food from
entering the lungs, (4) opening of the upper esophageal
sphincter by relaxation of the cricopharyngeal muscles and
by movement of the larynx anteriorly and superiorly to
enable the bolus to pass into the esophagus, (5) epiglottic
inversion, and (6) pharyngeal contraction to push the food
through the pharynx and the esophagus. All these actions
occur in the pharynx within 1 s and must be appropriately
coordinated for the swallow to be safe and efficient [17,18].
Pathophysiology of Swallowing Disorders
Post-RT swallowing disorders are due to primarily neuro-
muscular fibrosis and radiation-induced edema [19,20]. RT
induces hyperactivation through hydroxyl radicals of trans-
forming growth factor-b1 (TGF-b1) which plays a role in
collagen deposition and degradation. This leads to fibrosis
and the resulting abnormal motility of deglutition muscles as
impaired pharyngeal contraction and laryngeal elevation
responsible for dysphagia, aspiration, and stenosis [21].
Second, sensory changes in the oral cavity and the pharynx
also play a role in post-RT swallowing disorders by changing
the patient’s perception of swallowing [17,22]. There are
hypotheses that CRT can have an effect on innervation of the
larynx and pharynx, causing loss of laryngeal sensation,
motor function, and normal peristalsis [18]. Obviously,
xerostomia after RT due to the inclusion of salivary glands in
the radiation field contributes to swallowing problems.
Xerostomia is associated with difficulties in mastication and
delayed initiation of the swallowing reflex because of
decreased bolus lubrication due to the lack of saliva [17]. It
also negatively affects the patient’s overall perception of
swallowing quality and comfort of eating [19,22].
Incidence of Dysphagia
Pretreatment Dysphagia and Aspiration Rate (Table 1)
Dysphagia can exist before treatment as a result of the
extent of the tumor which can involve the motility of
structures that contribute to swallowing. Dysphagia rate
and severity therefore depend on tumor stage and locali-
zation, with the most severe complaints in more advanced
locoregional stages [23]. Laryngeal and hypopharyngeal
cancer patients aspirate most frequently before treatment
which is reflected by the high degree of pharyngeal and
esophageal impairment [24–26].
Post-Treatment Dysphagia (Table 2)
The severity of post-RT swallowing disorders is dependent
on several factors: total radiation dose, fraction size, frac-
tionation schedule, target volumes, interfraction interval,
treatment techniques such as the use of intensity-modulated
radiotherapy treatment (IMRT), addition of concurrent
chemotherapy, smoking during and after RT, PEG tube
feeding or prolonged (
[1–2 weeks) nil per os, depression,
and poor mental health [17,27–30]. The meta-analysis of
Machtay et al. [29] showed that older age, advanced tumor
stage, larynx/hypopharynx primary site, and neck dissection
after concurrent CRT are the main risk factors for severe
late toxicity. An average rate of 50% dysphagia in
advanced-stage HNC after CRT is reported [31]. However,
it should be noted that the incidence of dysphagia is perhaps
underreported in trials because clinical judgment often
underestimates the severity [32].
Little is known about the evolution of swallowing
problems after CRT, but dysphagia and aspiration can begin
or significantly worsen years after treatment. This is prob-
ably due to submucosal effects such as fibrosis and vascular
and nerve (sensory and motor) injury [19]. Nguyen et al.
[32] reported that the severity of dysphagia decreased in
32%, remained unchanged in 48%, and worsened in 20% of
their patients 1 year or more following HNC treatment.
Goguen et al. [33] described dysphagia as slowly but only
partly resolving after 6–12 months following CRT for
advanced HNC. In another study on nasopharyngeal cancer
140 N. Platteaux et al.: Dysphagia in Chemoradiotherapy Patients
123
patients treated with RT, a continuous deterioration of
swallowing function over time was seen [34] (Table 3).
Measuring and Reporting Dysphagia
Subjective Scoring
Several scoring systems are available to measure and report
dysphagia.
Patient-reported dysphagia can be assessed by quality-
of-life (QOL) questionnaires like the European Organiza-
tion for Research and Treatment of Cancer (EORTC)
global Q30 and Head and Neck (H&N35) [31,35]. The
latter is a specific questionnaire for HNC patients and
scores xerostomia, swallowing, and eating [35,36]. Two
other commonly used questionnaires for subjective
assessment are the Performance Status Scale for HNC
patients (PSS-H&N) and the MD Anderson Dysphagia
Inventory (MDADI). The PSS is a rapid, clinician-rated
Table 1 Overview from literature of pretreatment dysphagia
Tumor stage/site No. of
patients (N)
% Dysphagia % Aspiration Refs.
T2 or more, oral,
pharyngeal, and
laryngeal cancer
352 Oral: 28.2%, pharyngeal:
50.9%, laryngeal: 28.6%
Pauloski et al. [25]
Stage III–IV, HNC 79 Oral cavity: 14%, oropharyngeal:
30%, laryngeal: 67%,
hypopharyngeal: 80% VFS
Stenson et al. [26]
Stage II–IV, HNC 63 17% MBS Nguyen et al. [14]
Stage IV, HNC 22 14% VFS Eisbruch et al. [12]
Stage III–IV, HNC 27 41% VFS (45% silent–55% overt) Rosen et al. [83]
Stage III–IV, oropharyngeal,
nasopharyngeal cancer
36 8% VFS Feng et al. [78]
All tumor stages/sites 236 Grade 3–7: T1–T2: 20%,
T3–T4: 31%, oral cavity:
5%, laryngeal: 29%,
oropharyngeal: 33%,
hypopharyngeal: 52% VFS
Nguyen et al. [23]
HNC head and neck cancer, VFS videofluoroscopy, MBS modified barium swallow
Table 2 Overview from literature of post-treatment dysphagia
Tumor stage/site Therapy N% Dysphagia % Aspiration Refs.
Stage II–IV, HNC CRT 63 59% overall/ 33%
MBS
Nguyen et al. [14]
Locally advanced HNC CRT 55 45% severe 36% grade 6–7
MBS
Nguyen et al. [21]
39% grade 4–5
Stage IV, HNC CRT 20 65% early (1–3 months)
62% late (6–12 months)
VFS
Eisbruch et al. [12]
Stage III–IV, oropharyngeal,
nasopharyngeal cancer
CRT 36 44% early Feng et al. [77,78]
8% strictures
VFS
All stages, oropharyngeal cancer (C)RT 81 23% grade 3–4 Levendag et al. [68]
Stage III–IV, oral cavity, oropharynx,
hypopharynx
CRT 10 13% early
VFS
Smith et al. [19]
Nasopharyngeal cancer RT 31 41.9% silent Wu et al. [84]
FEES
HNC head and neck cancer, VFS, videofluoroscopy, MBS modified barium swallow, FEES functional endoscopic evaluation of swallowing,
(C)RT (chemo)radiotherapy, RT radiotherapy
N. Platteaux et al.: Dysphagia in Chemoradiotherapy Patients 141
123
instrument consisting of three subscales: normalcy of diet,
public eating, and understandability of speech. Ratings
range from 0 to 100, with higher scores representing closer-
to-normal functioning [37,38]. The MDADI is a validated,
dysphagia-specific QOL instrument and consists of 20
questions with global, emotional, functional, and physical
subscales. It is patient-friendly and easy to understand and
complete by patients [39,40]. Another cancer-specific
QOL instrument reported in literature is the Functional
Assessment of Cancer Therapy for head and neck (FACT-
G& H&N). This questionnaire is completed by the patient
and yields a global QOL score (FACT-G: range 0–120
points) comprising six subscales: physical, social, rela-
tionship with doctor, emotional and functional well-being,
and H&N concerns [37,38,41].
Observer-based dysphagia can be assessed by recording
acute toxicity during the first 3 months after RT using
Common Terminology Criteria for Adverse Events
(CTCAE) [42] and by recording late toxicity using the
Radiation Therapy Oncology Group (RTOG)/ EORTC
Late Radiation Morbidity Scale [43,44].
Objective Scoring
For objective assessment of swallowing function a video-
fluoroscopy [VF; often known as modified barium swallow
(MBS)] can be performed (Fig. 1). It is a validated stan-
dard method, developed by Logemann, that allows viewing
and recording of the structures and dynamics of the swal-
lowing process [45,46]. The whole assessment focuses on
bolus manipulation, bolus control, and bolus passage
including cohesion, motility, and timing [12,17]. The
findings of each patient are scored using the Swallowing
Performance Scale (SPS) (Table 4). This is a validated and
accurate assessment of dysphagia severity by combining
clinical and radiographic information. The severity of
dysphagia is graded on a scale of 1–7 [12,14,17].
Pathological Features Seen on Videofluoroscopy
Abnormal swallowing can be defined in terms of the
amount and incidence of aspiration and penetration,
Table 3 Overview from literature of chronic dysphagia
Tumor stage/site Therapy N% Dysphagia % Aspiration Refs.
All stages and tumor sites CRT/surgery ±RT 74 49%
MBS
Nguyen et al. [85]
Locally advanced HNC CRT/surgery ±RT 25 32%
VFS
Nguyen et al. [32]
Stage III–IV, oral cavity,
oropharynx, hypopharynx cancer
CRT 10 30%
VFS
Smith et al. [19]
Locally advanced HNC Induction
chemotherapy ?CRT
122 38.5% severe
MBS
Caudell et al. [27]
Nasopharyngeal cancer RT 49 22% silent
VFS
Hughes et al. [86]
Nasopharyngeal cancer RT 71 71.8%
VFS
Chang et al. [34]
HNC head and neck cancer, VFS videofluoroscopy, MBS modified barium swallow, (C)RT, (chemo)radiotherapy, RT radiotherapy
Fig. 1 Normal swallowing function on videofluoroscopy
142 N. Platteaux et al.: Dysphagia in Chemoradiotherapy Patients
123
laryngeal sensation (response to penetrant/aspirate), and
residue/pooling after the swallow [12]. Also, abnormal
timing or duration of each swallowing phase can be eval-
uated as beyond the range found in normal controls [12,17,
25]. The most frequently found VF abnormalities after
CRT are (1) reduced inversion of the epiglottis, (2) reduced
laryngeal elevation and closure resulting in poor airway
protection and promoting penetration and aspiration, (3)
reduced base-of-tongue retraction resulting in reduced
tongue base contact with the posterior pharyngeal wall, (4)
delay in triggering the pharyngeal swallow, (5) pharyngeal
hypocontractility, (6) incomplete relaxation of cricopha-
ryngeal muscles leading to reduced cricopharyngeal
opening which results in pooling of residue in the piriform
sinuses and valleculae [12,17,24,47] (Fig. 2).
VF can ideally be combined with manometry (mano-
fluoroscopy), first developed by Mc Connel [48].
Manometry involves measurement of the pressures in the
pharynx, upper esophageal sphincter, and esophagus. It is
most often used to look at the relaxation and the contrac-
tion of the esophageal musculature. Ideally, it can be per-
formed by using a solid-state catheter. Manofluoroscopy
permits correlation of motion of anatomic structures with
the resulting intraluminal pressures [49].
A second objective tool to evaluate swallowing dys-
function is functional endoscopic evaluation of swallowing
(FEES), first described by Langmore [50]. It visualizes the
pharynx from above by placing an endoscopic tube, with-
out anesthesia, transnasally such that the end of the tube
hangs over the end of the soft palate. The anatomy and
function of the soft palate, tongue base, pharynx, and
larynx are assessed during speech, spontaneous move-
ments, dry swallowing, and swallowing of various consis-
tencies of liquid and food. Sensitivity of the pharynx is
assessed by light touch with the tip of the endoscope.
Premature leakage of food or fluid from the mouth into the
pharynx before a voluntary swallow can be assessed.
Residue in vallecula epiglottica, aryepiglottic region, and
piriform sinus can be assessed together with laryngeal
penetration and aspiration. The patients’ reaction to resi-
dues or aspiration can be noted [51]. FEES can be com-
bined with sensory testing (FEESST). The sensory-testing
procedure includes air pulse stimuli delivered to the
mucosa innervated by the superior laryngeal nerve through
a port in the flexible endoscope [52].
When MBS and FEES are compared, the principal
advantage of the FEES seems to lie in the detection of
aspiration and for MBS in the dynamic evaluation of the
oral and esophageal phases of swallowing. FEES is easier
and it can be performed bedside without radiation exposure
using portable equipment. It also can frequently be repe-
ated and is more cost-effective than VF [53,54]. Disad-
vantages of FEES are that it provides only indirect
information about oral cavity function, the moment of
swallowing itself, and esophageal disease and that it is
more observer dependent [50]. Thus, FEES is often used as
an adjunct to MBS rather than an alternative [55].
Table 4 The Swallowing Performance Scale (SPS)
Grade 1: normal
Grade 2: within functional limits—abnormal oral or pharyngeal stage
but able to eat a regular diet without modifications or swallowing
precautions
Grade 3: mild impairment—mild dysfunction in oral or pharyngeal
stage; requires a modified diet without need for therapeutic
swallowing precautions
Grade 4: mild-to-moderate impairment with need for therapeutic
precautions—mild dysfunction in oral or pharyngeal stage; requires
a modified diet and therapeutic precautions to minimize aspiration
risk
Grade 5: moderate impairment—moderate dysfunction in oral or
pharyngeal stage, aspiration noted on exam; requires a modified diet
and swallowing precautions to minimize aspiration risk
Grade 6: moderate-severe dysfunction—moderate dysfunction of oral
or pharyngeal stage, aspiration noted on exam; requires a modified
diet and swallowing precautions to minimize aspiration risk; needs
supplemental enteral feeding support
Grade 7: severe impairment—severe dysfunction with significant
aspiration or inadequate oropharyngeal transit to esophagus, nothing
by mouth; requires primary enteral feeding support
Fig. 2 Aspiration and pharyngeal hypocontraction on videofluo-
roscopy
N. Platteaux et al.: Dysphagia in Chemoradiotherapy Patients 143
123
Third, direct endoscopy under anesthesia can be used to
visualize strictures in the inferior pharyngeal muscles at the
postcricoid level of the hypopharynx [56].
Finally, CT scans can be used to evaluate the thickness
of several swallowing structures like the pharyngeal con-
strictor muscles, the supraglottic larynx, and the glottic
larynx, which is usually increased after RT [56].
Correlation Between Subjective and Objective Scoring
There is considerable discrepancy in the literature con-
cerning the correlation between objective and subjective
swallowing evaluation. For instance, from a study of 132
HNC patients, Pauloski et al. [57] reported excellent cor-
relation between patients’ perception of dysphagia and their
actual swallowing function measured with VF. Patients
with complaints of dysphagia had lower oropharyngeal
swallow efficiency, longer oral and pharyngeal transit
times, more oral and pharyngeal residue, more aspiration,
took less nutrition by mouth, and were less able to eat all
food consistencies. It appears that pharyngeal function has a
greater impact on swallowing perception than oral function.
In contrast, from a study of 116 HNC patients, Jensen et al.
[58] found little correlation between patient-assessed
symptom severity and observer-based toxicity scoring. The
observer-based rating of side effects underestimated the
patient-scored side effects using QOL questionnaires.
Impact on Quality of Life
Swallowing dysfunction has a clear negative impact on the
global QOL of HNC patients. Dysphagia leads to longer
eating times, inability to eat different types of food, and fear
or inability to eat in public, which in turn results in social
isolation and depression [13]. Obviously, prolonged unnat-
ural feeding may induce major psychological distress
because it causes discomfort and distorts the patient’s self-
image [13]. Nguyen et al. [13] showed that the severity of
dysphagia correlates with a compromised QOL, anxiety, and
depression. Murry et al. [59] described that swallowing and
QOL are often compromised in advanced HNC before
treatment, they further decrease during CRT, and they begin
to improve shortly after treatment with a marked improve-
ment 6 months after treatment. They also showed that QOL
generally follows a two-stage recovery: first the psycho-
logical aspects improve, followed by the physical aspects
associated with swallowing [59]. The best predictor of 12-
month global QOL seems to be the pretreatment global QOL
[38,60]. Langendijk et al. [15] also described that the effect
of late radiation-induced toxicity, particularly on swallow-
ing function and salivary gland function, has a significant
impact on the more general dimensions of health-related
(HR) QOL, such as physical, social, and mental health. They
further described that the impact of radiation-induced
swallowing dysfunction is greatest in the first 12 months
after completion of RT and gradually decreases at 18 and
24 months [15]. Abendstein et al. [61] evaluated long-term
QOL 5 years after treatment and noted an improvement in
global HRQOL in 40%, deterioration in 25%, and no change
in 35% of patients. Dysphagia also leads to prolonged tube
feeding dependence as described above. Time dependence
for tube feeding ranges in the literature from 4 to 21 months
with a median of 9 months [6,21].
Treatment of Swallowing Disturbances
Management of swallowing disorders resulting from HNC
treatment includes both compensatory treatment procedures
and specific rehabilitation programs. Obviously, a truly
multidisciplinary team approach is needed, consisting of the
treating oncologist, a speech-language pathologist, a dieti-
cian, and sometimes a gastroenterologist for dilatation [17].
Compensatory Treatment Procedures
The purpose of the compensatory treatment procedure is to
improve bolus flow and reduce aspiration. These procedures
should be introduced during MBS to evaluate the immediate
results. The following compensatory treatment procedures
are generally used: postural techniques, increasing sensory
input prior to or during the swallow, modification of
bolus size/volume and consistency of food, and deletion of
Table 5 Overview from literature of the results of swallowing therapy
Tumor stage/site Therapy NTreatment Results Refs.
Locally advanced HNC CRT (n= 24) 41 Swallowing therapy
for aspiration
32% improvement dysphagia Nguyen et al. [87]
Postoperative
RT (n= 17)
36% improvement aspiration
All stages, oral cavity,
pharyngeal-laryngeal cancer
CRT 9 Super-supraglottic
swallow
Elimination (1) – reduction
of aspiration (2)
Logemann et al. [88]
HNC head and neck cancer, (C)RT (chemo)radiotherapy
144 N. Platteaux et al.: Dysphagia in Chemoradiotherapy Patients
123
specific food consistencies as the last resort [17,62,63].
Postural changes (like head positioning) are effective 75–
80% of the time in eliminating aspiration of at least one
bolus volume introduced by MBS [17,62,63].
Rehabilitation therapy procedures are designed to
improve the range of motion (ROM) of oral and pharyngeal
structures and sensory-motor integration. These therapy
procedures include therapy exercises and swallow maneu-
vers [17,63]. Therapy exercises are exercises that
strengthen the tongue to increase the oral tongue and ton-
gue base volume and function. There are also ROM exer-
cises that should improve bolus transit and clearance from
the oral cavity and pharynx [17,63]. So-called Shaker
exercises diminish upper esophageal sphincter (UES)-
related dysphagia by improving the duration and width of
the UES opening [64,65]. Swallow maneuvers such as
supraglottic swallow, super-supraglottic swallow, Men-
delsohn maneuver, effortful swallow, and tongue hold are
voluntary controls that can be used during swallow to
change selected aspects of neuromuscular control [17,63,
64].
Logemann et al. [18] suggests that function at 6 months
after treatment predicts long-term function. It is therefore
reasonable to maximize swallowing recovery by 6 months
after CRT. Waters et al. [66] also showed less benefit to
delayed swallowing therapy. A few results from literature
are given in Table 5.
Dilatation of Strictures
In the case of pharyngoesophageal strictures, it is some-
times necessary to perform a pharyngeal and cervical
esophageal dilatation [18]. Ahlawat et al. [67] reported that
endoscopic dilatation of proximal esophageal strictures
gives adequate dysphagia relief in 84% of their treated
HNC patients.
Prevention of Dysphagia
As described above, dysphagia has a significant impact on
QOL and prevention of this serious late side effect is of
paramount importance [68]. The three main approaches are
described below.
Radioprotectors
Radioprotector amifostine (WR2721) is a cytoprotective
agent. It is a thiol compound that protects normal tissues
against radiation through the binding of the sulfhydryl
group with hydroxyl radicals. It has been tested for
mucosal protection and prevention of late dysphagia fol-
lowing RT for HNC with mixed results [69]. In HNC
Table 6 UZ Leuven guidelines to delineate the dysphagia-aspiration-related structures
OAR Superior border Inferior border Anterior border Posterior border
1. Superior pharyngeal constrictor
(SPC) muscles
Caudal tip of pterygoid
plates (hamulus)
Upper edge of hyoid bone Widest diameter of rhinopharynx,
base of tongue, hyoid bone,
and larynx
Cervical vertebra or
prevertebral
muscles
2. Middle PC muscles (MPC) Upper edge of hyoid bone Lower edge of hyoid bone
3. Inferior PC (IPC) muscles Lower edge of hyoid bone Lower edge of cricoid cartilage
4. Base of tongue (BOT) Below soft palate Upper edge of hyoid bone Posterior third of the tongue
5. Supraglottic larynx (SGL) Top of the piriform sinus and
aryepiglottic fold
Upper edge of the cricoid cartilage Anterior tip of the thyroid cartilage Cornu of the thyroid
cartilage
6. Glottic larynx (GL) At the level of the cricoid cartilage
7. Upper esophageal sphincter
(UES) ?m.cricopharyngeus
Lower edge of cricoid cartilage Upper border of trachea Subglottic larynx Cervical vertebra
8. Esophagus Upper border of trachea First 2 cm of esophagus Trachea Cervical vertebra
N. Platteaux et al.: Dysphagia in Chemoradiotherapy Patients 145
123
patients treated with concomitant CRT ±amifostine,
given before each chemotherapy cycle and less than
45 min before RT, less acute nonhematologic (mucositis,
xerostomia, dysphagia, loss of taste, and dermatitis) and
hematologic side effects and less chronic side effects
like radiation-induced xerostomia are observed [69–71].
Fig. 3 Delineation of
swallowing structures on CT
slices. (Color figure online)
146 N. Platteaux et al.: Dysphagia in Chemoradiotherapy Patients
123
Table 7 Correlation between subjective and objective swallowing function, QOL, and DVH parameters
Tumor stage/site/therapy NSubjective Objective DVH parameters Refs.
All stages, oropharyngeal cancer, RT
(IMRT), chemo
81 Severe grade 3–4 dysphagia/
dysphagia QOL
Mean SPC-MPC doses: steep dose-
effect relationship
Levendag et al. [66]
Locally advanced HNC, (CT) IMRT 27 (1) Patient report diet and PEG
tube persistence at 1 year
(2) Weight loss
(1) Doses to the aryepiglottic folds,
false vocal cords, lateral pharyngeal
walls
(2) Doses to the aryepiglottic folds
Dornfeld et al. [89]
All stages, oropharyngeal cancer,
(CT) RT (IMRT)
67 (24) Swallowing-related QOL Total FEES score Mean SPC dose Teguh et al. [54]
All stages, oropharyngeal,
nasopharyngeal cancer, (CT) RT
(IMRT)
132 Swallowing-related QOL SPC dose Teguh et al. [20]
Stage III–IV, oropharyngeal,
nasopharyngeal cancer, CT IMRT
36 (1) Worsening patient-reported
solid swallowing and
observer-rated swallowing
scores
(4) Worsening patient-reported
liquid swallowing
(1) Aspiration VFS
(2) Strictures
(3) Reduced laryngeal
elevation, epiglottic inversion
(1) Mean SPC & MPC
doses [60 Gy, PC V65 [50%,
GSL V50 [50%
(2) PC V70 [50%
(3) mean PC dose, mean GSL dose
(4) mean PC dose, mean esophageal
dose,
Feng et al. [77,78]
Advanced stage, pharynx cancer, RT 35 EORTC QOL FEES variables DVH of supraglottic region Jensen et al. [51]
All stages, nasopharyngeal cancer,
IMRT
28 Acute grade 3 dysphagia/
feeding tube duration
Mean pharyngoesophageal dose Fua et al. [90]
All stages, HNC, IMRT ±CT 96 Aspiration/stricture MBS V50 larynx, V50 IPC Caglar et al. [76]
Locally advanced HNC 53 Late dysphagia/QOL Mean doses and V50 of MPC/IPC/
supraglottic larynx
Dirix et al. [91]
HNC head and neck cancer, RT radiotherapy, CT chemotherapy, IMRT intensity-modulated radiotherapy, QOL quality of life, EORTC European Organization for Research and Treatment of
Cancer, PC pharyngeal constrictor muscles (Ssuperior, Mmiddle, Iinferior), GSL glottic supraglottic larynx, PEG percutaneous endoscopic gastrostomy, VFS videofluoroscopy, MBS modified
barium swallow, FEES functional endoscopic evaluation of swallowing, DVH dose volume histogram
N. Platteaux et al.: Dysphagia in Chemoradiotherapy Patients 147
123
However, the risk of tumor cell protection by amifostine is
an issue that needs to be addressed [72]. Currently there is
no good level I evidence to suggest that radioprotectors can
alleviate dysphagia so they should be carefully evaluated in
prospective clinical trials.
Radiation Modifications
As we know from the literature, there is a relationship
between xerostomia and dysphagia after CRT for HNC
[22]. The reduction of xerostomia by preserving the sali-
vary gland function can possibly decrease dysphagia. This
can be done by using parotid gland-sparing conformal RT
or by using IMRT [73,74]. IMRT modulates the intensity
of the radiation beam to decrease the doses to normal
structures without compromising the doses to the target. A
parotid gland mean dose of 26 Gy or less should be the
goal in order to spare gland function and reduce xerostomia
and dysphagia [75].
We also know from the literature that dysphagia-
aspiration-related structures (DARS), damage to which
causes dysphagia and aspiration, are the superior, middle,
and inferior pharyngeal constrictor muscles (scm, mcm,
icm), cricopharyngeal muscles, esophagus, the glottic lar-
ynx, and the supraglottic larynx [56,68,76] (Table 6;
Fig. 3). IMRT can be used to reduce the doses to DARS by
applying dose constraints to them in an attempt to decrease
dysphagia [74,77,78]. Numerous retrospective studies
show a correlation between either subjective or objective
assessment of dysphagia and dose volume parameters of
anatomic swallowing structures (Table 7). These correla-
tions suggest the reduction of the mean doses and the
volumes of the DARS structures that receive 50 Gy or
more (V50) in an attempt to reduce swallowing difficulties
[51,68,76–78]. Partial sparing of the pharyngeal con-
strictors is expected to confer a benefit if primary distal
motor or sensory neural deficits and primary muscle dys-
function play a role in dysphagia [56].
Another way to decrease dysphagia is by more selective
delineation of elective nodal volumes. To spare the parotid
gland we can start to delineate the elective neck nodes of
level II at the contralateral, uninvolved neck on the subd-
igastric level. We know from the literature that there are no
recurrences in these nodes in selected patients [79]. This
technique leads to a decrease in xerostomia which has an
impact on swallowing. We can also delineate only the
Fig. 4 Plan of patient with laryngeal cancer cT3N0 treated with
IMRT. Delineation of following structures atongue base (blue),
clinical and planning target volume (CTV and PTV) of elective nodes
(red), superior pharyngeal muscles (light blue), submandibular glands
(yellow,left;orange,right). bGross tumour volume (GTV) (red),
CTV boost (red) and PTV boost (orange), CTV and PTV of elective
nodes (red), inferior constrictor pharyngeus (green) lying in the high
dose region ([65 Gy). cPTV boost (orange), CTV and PTV of
elective nodes (red–red), m. cricopharyngeus (blue) lying in the high
dose region 70 Gy. (Color figure online)
b
148 N. Platteaux et al.: Dysphagia in Chemoradiotherapy Patients
123
lateral retropharyngeal neck nodes (medial from carotid
artery and lateral to the longus colli and capitis muscles)
while sparing the medial ones. The lateral retropharyngeal
neck nodes are involved mostly in metastasis sites, except
for the posterior pharyngeal wall where the medial nodes
also are involved [79–81]. These modifications can facili-
tate partial sparing of the pharyngeal constrictors and the
upper parts of the glottic and supraglottic regions by using
IMRT [77–79,81].
Not only better definition of the elective nodal volumes
but also reduction of the PTV margins can have an impact
on the doses to the swallowing structures. Nowadays, the
use of online imaging and correction of setup deviations
can lead to a reduction of the PTV margins from 5 to 3 mm
[78].
Knowing the correlation between the doses to swal-
lowing structures and dysphagia and presuming the highest
relapse rates in the therapeutic target volumes, we
hypothesize that we can reduce the doses to the elective
nodal volumes. A Belgian phase III multicenter trial that
randomizes HNC patients to receive 40 or 50 Gy to the
elective nodal volumes is ongoing. This trial aims to
decrease the severity and rate of swallowing disturbances
without compromising locoregional control (Fig. 4). Being
aware that sparing swallowing structures leads to steeper
dose falloff near the target in the vicinity of these struc-
tures, we hope to reach the same locoregional disease
control [56].
Exercises
Exercise programs are designed to improve swallow
physiology and possibly prevent or decrease the severity of
swallowing disorders before they develop. These exercises
were easily learned by the patients through instructions
from the speech pathologists [17].
ROM exercises and resistance exercises are available for
the tongue, lips, larynx, and hyoid-related structures. The
most frequently performed pretreatment swallowing exer-
cises are the Mendelsohn maneuver, tongue hold, tongue
resistance, effortful swallow, and Shaker exercise. These
exercises are performed five times a day and are started
2 weeks before RT [39]. The literature has few studies that
show an improvement in post-treatment swallowing func-
tion and QOL from performing pretreatment swallowing
exercises (Table 8).
Avoidance of nothing-by-mouth periods can help to
diminish difficulty swallowing after treatment. Patients
should be encouraged to swallow throughout the course of
their RT or CRT in an attempt to prevent long-term dete-
rioration in swallowing function [18,27,82].
Conclusion
Dysphagia is a common and serious side effect in HNC
patients. It can exist before treatment due to tumor site and
stage and/or be a sequel of treatment strategies such as
surgery and chemoradiotherapy. It has a significant impact
on the QOL because eating is impaired and this has a major
impact on social well-being. There are subjective and
objective scoring systems to measure dysphagia severity
and its impact on QOL. Treatment of swallowing disorders
by compensatory and rehabilitation treatment procedures is
rarely effective, thus prevention is paramount. Preventing
or diminishing dysphagia can be achieved by treatment
modification by using IMRT to try to spare or decrease the
doses to the dysphagia-aspiration-related structures and the
salivary glands without compromising locoregional disease
control. Other ways to prevent or diminish dysphagia can
be adding radioprotectors or performing exercises before
RT. Diminishing dysphagia by these techniques could
potentially ameliorate the QOL of HNC patients. However,
considerable research remains to be done.
Acknowledgments This work was supported by grants from the
Flemish League Against Cancer (VLK) and the Clinical Research Fund
(KOF) from the University Hospitals Leuven. Piet Dirix is a research
assistant (aspirant) of the Research Foundation-Flandres (FWO).
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Nele Platteaux MD
Piet Dirix MD
Eddy Dejaeger MD, PhD
Sandra Nuyts MD, PhD
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