Marilene B. Wang, MD
Traditional treatments for head and neck cancers involve surgery and RT, but with newer, more targeted chemotherapy options available, many cancer types can be treated with CRT. Because CRT is often more targeted, it is hoped that more tissue and structure can be spared from damage. Unfortunately, preservation does not always translate to normal, natural swallowing ability.
Dysphagia is a main predictor of poor posttreatment quality of life in patients with head and neck cancer, and current clinical interventions to address this symptom in patients undergoing RT and CRT are limited; those that are currently available follow a therapeutic or rehabilitative model rather than a preventive one.
During early radiation treatment, adverse events such as odynophagia, mucositis, or xerostomia can limit the patient’s desire and ability to swallow, and even brief episodes of oropharyngeal rest or lack of exercise during CRT may be associated with prolonged dysphagia.
Marilene B. Wang, MD, professor-in-residence in the Department of Head and Neck Surgery at UCLA’s David Geffen School of Medicine and colleagues, identified 85 patients who underwent RT or CRT at a tertiary care academic medical center from 2007-2012 to participate in the study evaluating whether an SPP implemented before, during, and after RT and CRT could help maintain posttreatment swallow function. Patients were divided into two groups based on self-reported compliance, with compliant defined as performance of at least one full set of exercises per day (n = 57) and noncompliant (n = 28) as performing less than one full set of swallowing exercise per day.
The aim of the program was to maintain range of motion of oral, pharyngeal, and laryngeal structures involved in swallowing and limit the fibrosis associated with radiation that often leads to restricted range of motion resulting in dysphagia, as well as to encourage patients to continue oral intake as much as possible, despite dysgeusia and odynophagia.
As part of the SPP, every patient underwent evaluation by a speech-language pathologist (SLP) prior to treatment. Patient demographic data, primary tumor site, stage of tumor, type of treatment (RT or CRT), radiation dose administered to the primary site, and other relevant information were recorded. Patients used a form to track their swallowing exercises performed and completed, and brought the form to each weekly SPP visit.
Other aspects of the protocol included a pretreatment swallow assessment conducted with patients 2 weeks prior to cancer treatment involving education about their cancer and expected treatment adverse events, assessing for pretreatment dysphagia, as well as introducing the exercise program.
Swallowing exercises were reinforced by the SLP with the aim of increasing adherence and assessing performance. The exercises consisted of gargling liquid for 10 seconds 10 times, effortful swallowing 10 times, performing a Mendelsohn maneuver 10 times, chugging 3 ounces at once, tongue protrusion 10 times, tongue press 10 times, and Shaker head lifts 3 times. These sets were performed 3 times daily (3 sets), except for the Shaker exercise, which was performed once per day (1 set).
One month after completion of therapy, 31 of the compliant patients (54.4%) were eating a regular, chewable diet, versus just 6 in the noncompliant cohort (21.4% [P = .008]). In addition, fewer compliant patients were found to be G-tube dependent (22.8%) compared with 53.6% of those who did not perform the exercises consistently (P = .008).
The real benefit of complying with swallow exercises before and during RT and CRT, noted researchers, is that the swallowing function is better preserved at the conclusion of therapy and thus patients benefit immediately from improvement or maintenance of swallowing as they do not have to wait 3 to 12 months after therapy for swallowing potential to return.
The authors concluded that compliance with an SPP leads to a faster return to normal diet and prevention of future esophageal stenosis. Larger and longer-term, prospective, randomized studies are needed for assessment of the relationship between swallow preservation therapy and changes in quality of life.
“Our results demonstrate that compliance with swallow therapy during radiation or chemoradiation treatment is beneficial to patients’ retaining their ability to swallow after treatment is over,” said Wang. “The real benefit of this compliance is that patients benefit immediately after treatment, and for a prolonged time afterward. Attending our weekly program, fully committing to the exercises, and being monitored by our staff appears to have a significantly measurable effect on these patients.”
The study was published online ahead of print in the journal Otolaryngology—Head and Neck Surgery on August 27, 2013.
Nurse Perspective on Swallowing Exercises
Clinical Nurse Specialist
The James Cancer Hospital
The Ohio State University Comprehensive Cancer Center
Patients with head and neck cancer have a unique set of sequela that begins prior to treatment and persists or worsens during treatment and after. This is especially true of dysphagia. In this study, Wang, et al, aimed to decrease the effects of dysphagia with the use of swallowing exercises prior to and throughout treatment. The results, as anticipated, showed that those patients who completed their exercises as prescribed had better outcomes than those who did not follow through. The authors pointed out that specialized assessments and education are needed in order for patients to reach the best outcomes. Successful treatment of patients with head and neck cancer is an excellent example of the need for multidisciplinary care.
In this study, the speech-language pathologist (SLP) and physician assessed the patients for swallowing difficulties and provided exercises designed to improve their swallowing ability. Where I believe the study could be even stronger is to involve the nurse in the process. The physician and SLP only saw the patient at certain intervals to assess compliance as well as outcomes. It was pointed out that there were a variety of reasons for noncompliance as well as dropout rates. However, if the nurse— who sees the patient on a much more frequent basis—were involved, perhaps compliance would have been higher with even better outcomes.
It is important that nurses are familiar with the phases of swallowing as well as indications of swallowing difficulties. Swallowing occurs in four phases. In the oral preparatory phase, food is ground and manipulated in the mouth to form a bolus appropriate for safe swallowing. The oral phase is initiated when the tongue presses the food bolus against the hard palate while the soft palate rises and the bolus moves backwards to the tonsillar pillars. In the pharyngeal phase, the food is propelled posteriorly while the larynx closes to the level of the vocal chords, the epiglottis covers the laryngeal vestibule, and the pharynx constricts. Finally, in the esophageal phase, peristaltic contractions of the muscles result in the bolus moving into the stomach. The entire process takes less than 10 seconds.
It is clear that a myriad of structures need to be intact and working together for adequate swallowing to occur. The nurse should be aware of triggers that may indicate an abnormality in one or more of these phases. Such triggers include the inability to control food, liquids, or saliva in the mouth pocketing of food in the cheek, excessive chewing, drooling, coughing, choking or throat clearing before, during, or after swallowing, abnormal voice quality after swallowing, “wet” or “gurgly” voice, congestion following a meal, complaints of food “sticking” in the throat, nasal regurgitation and weight loss.1,2
As this study pointed out, early interventions for swallowing difficulties were effective in returning the patient to a normal diet as well as decreasing the need for feeding tubes. The nurse is in the ideal position to assess the patient on an ongoing, frequent basis and refer to the proper healthcare provider for follow-up. When the physician, SLP, nurse, dietician, physical therapist, radiation therapist, and other caregivers involved in the patient’s care all work together, the outcomes can only be better. I think it would be an interesting adjunct to this study to repeat it with nurses involved in more frequent assessment to see if early detection of problems with proper consults for intervention would increase the compliance of patients. Who knows, you may see that coming soon.
- Molseed L. Clinical evaluation of swallowing: The nutritionist’s perspective. In Murry CA, ed. Comprehensive Management of Swallowing Disorders. San Diego, CA: Plural Publishing; 2006: 59.
- Murphy BA, Gilbert J. Dysphagia in head and neck cancer patients treated with radiation: assessment, sequelae, and rehabilitation. Semin Radiat Oncol. 2009;19(1):35-42.