99 Swallowing Function and Implications in Head and
Neck Cancer
Barbara P. Messing, Clare Burns, Laurelie Wishart, Bena Brown
KEY POINTS
• Understanding normal swallow physiology and
pathophysiology is essential in the evaluation and
management of dysphagia in patients with head
and neck cancer.
• Evaluation of dysphagia in patients with head and neck
cancer requires comprehensive assessment using clinical
and instrumental modalities to determine the underlying
pathophysiological and surgically altered structures.
• Dysphagia can be caused by the tumor itself or from
interventions prescribed to treat the head and neck
cancer.
• Management of dysphagia is directed to each patient’s
specific swallow pathophysiologic abnormality and
nutritional status.
• Management of dysphagia may involve recommendations
for posturing/positioning modifications, oropharyngeal
exercises, lymphedema therapy, sensory feedback,
volitional swallowing compensatory strategies, and diet/
fluid modifications.
INTRODUCTION
The annual incidence of head and neck cancer (HNC) is esti-
mated at 686,328 new cases and 376,000 cancer-related deaths
worldwide.1–3 Developing in the mucosal lining of the oral cavity,
oropharynx, nasopharynx, hypopharynx, and larynx, the histology
of HNC is predominanly squamous cell carcinoma (90%) with
human papilloma virus–related SCC being one of the main causes
for the growing incidence of oropharyngeal HNC cancer.4,5 Patients
with HNC are at a high risk for developing dysphagia due to
the presence of the tumor itself or the cancer treatment. Up to
two-thirds of patients present with dysphagia at the time of HNC
diagnosis.6–10 Short-term or long-term swallowing complications
following treatment can significantly impact nutritional intake and
quality of life.11–14 With increasing cases of HPV-related SCC in
younger individuals, coupled with improved survival of HPV-SCC
over non-HPV SCC, the demands on treatment and long-term
rehabilitation, including dysphagia services, are only expected to
increase in the future.15–18 The purpose of this chapter is to describe
swallow physiology and pathophysiology associated with HNC,
the procedures for the assessment of dysphagia, and the effects of
surgical and nonsurgical HNC treatment on swallowing function.
ORAL PREPARATORY PHASE
The oral preparatory or bolus preparation phase of swallow involves
oral manipulation and/or preparation of saliva, fluids, and food.
There are multiple muscle groups that work synergistically to
facilitate the oral preparatory phase. The orbicularis oris is a circular
1466
muscle of the lips that serves to maintain oral competency during
bolus preparation and swallowing.19–21 Tension activated in the
buccinators prevents pooling of the bolus in the lateral and anterior
sulci.19,20 To maintain oral control of fluids, the posterior tongue
elevates to the soft palate to prevent the fluid bolus from entering
the pharynx.19 Mastication by the teeth enables the solid bolus to
soften and reduce in size, which is then mixed with saliva and
formed into a cohesive bolus through cyclical movements of the
jaw and tongue. The four extrinsic muscles of the tongue (genioglos-
sus, palatoglossus, styloglossus, and hyoglossus) work with the
intrinsic tongue muscles (superior longitudinal, inferior longitudinal,
transverse, and vertical) to move and position the bolus in prepara-
tion for swallowing. The hyoid bone is interestingly active during
the oral preparatory phase, because it has muscle connections to
the suprahyoid and infrahyoid muscles, thereby influencing the
movements of the jaw and tongue to some degree.22 Under vol-
untary control, the oral preparatory phase of swallowing may be
halted or modified at any time.19
ORAL PHASE
The oral phase involves timely and efficient transport of the bolus
into the pharynx. The tongue elevates to the superior alveolar
ridge then moves in an anterior to posterior direction. The soft
palate elevates through contraction of the levator veli palatine
and musculus uvulae, as the hyoglossus muscle of the tongue
contracts and depresses, providing an opening for the bolus to be
propelled into the pharynx (Fig. 99.1).19,20 Intrabolus propulsion
and pharynx driving forces propel the bolus into the pharynx
within approximately 1 to 1.5 seconds.21,23 Elevation of the soft
palate closes the velopharyngeal port, preventing nasal regurgitation
during the oropharyngeal phase of swallow.19
PHARYNGEAL PHASE
The pharyngeal stage of the swallow is physiologically important
because airway protection occurs during this phase in normal
swallowing. The oral preparatory and oral phases of the swallow
may be bypassed by reducing the consistency of food to liquid,
by syringing food into the back of the mouth, or by positioning
the head back so that gravity carries the food into the pharynx.
The pharyngeal stage of the swallow cannot be bypassed. The
pharyngeal phase involves bolus transport through the hypopharynx
into the proximal esophagus. The pharyngeal phase begins as the
pharyngeal swallow is triggered. This occurs once the leading
edge of the bolus has passed any point between the anterior faucial
arches and where the tongue base crosses the lower rim of the
mandible.24 It is theorized that a sensory recognition center in
the nucleus tractus solitarius of the medulla is responsible for
decoding sensory information detected from the oropharynx and
tongue, identifying the swallow stimulus, and relaying this informa-
tion to the nucleus ambiguous, which initiates the pharyngeal
swallow motor pattern.25 Research has demonstrated variability
in the “normal” onset of the pharyngeal phase of swallowing
associated with age and bolus-related variables, including consis-
tency, size, and use of verbal cueing.26–28 The normal “aging”
 CHAPTER 99 Swallowing Function and Implications in Head and Neck Cancer1466.e1

Abstract Keywords
99
Dysphagia (swallowing disorder) is a common sequela of head and speech-language pathologist
neck cancer (HNC). Dysphagia may result from the tumor or a oral preparatory phase
consequence of treatment-related effects. This chapter summarizes oral phase
the physiology of the oral preparatory, oral, and pharyngeal phases pharyngeal phase
of swallowing and describes clinical and instrumental assessments dysphagia
commonly used by speech-language pathologists in swallowing head and neck cancer
evaluation. The impact of HNC on swallowing function is swallow screen
discussed relating to the treatment modalities of radiotherapy, clinical swallowing examination
chemoradiation, and surgery. A summary of the commonly videofluoroscopic swallow study
observed symptoms and swallowing pathophysiology arising modified barium swallow study
from HNC is provided. The management of dysphagia associated flexible endoscopic evaluation of swallowing
with HNC is outlined, including the use of targeted strategies manometry
and exercises, along with specialist input from members of the ultrasonography
multidisciplinary team. radiotherapy
chemoradiation
systemic therapy
organ preservation
lymphedema
compensatory strategies
rehabilitation
 CHAPTER 99 Swallowing Function and Implications in Head and Neck Cancer
Bolus
Tongue Cheek
Mandible
Front view of oral cavity
Fig. 99.1 The anterior and lateral views of the tongue position in holding a bolus immediately before initiating
the oral stage of the swallow.
pharyngeal swallow has been found to be triggered later (i.e.,
below the lower rim of the mandible) without impacting the
frequency of airway intrusion.27,28
A number of physiological responses occur as a result of
pharyngeal swallow triggering: (1) elevation and retraction of the
velum and complete velopharyngeal closure to prevent nasal
regurgitation and sustain interbolus pressures; (2) base-of-tongue
retraction to contact the posterior pharyngeal wall (PPW); (3)
progressive superior-inferior contraction of the pharyngeal constric-
tor muscles creating a driving force or pressure on the bolus; (4)
elevation and anterior movement of the hyoid and larynx facilitating
approximation of the hyoid with anteriorly tilting arytenoid
cartilages, and deflection of epiglottis, combined with (5) closure
of the larynx at the true vocal folds and false vocal folds prevents
airway penetration and aspiration during the swallow; and finally,
(6) relaxation of the upper esophageal sphincter (UES) to allow
bolus passage from the pharynx into the esophagus.29–31 In normal
swallowing function, the pharyngeal phase occurs within 1 to 1.5
seconds depending on bolus volume and viscosity.32
The following sections discuss the features that facilitate a safe
and efficient pharyngeal swallow.
Neuromuscular Activities Characteristic of
the Pharyngeal Swallow
When the swallowing reflex is triggered, the brainstem swallowing
center programs certain neuromuscular activities to occur. The
pharyngeal swallow is mediated in the lower brainstem (the medulla)
in the reticular formation immediately adjacent to the respiratory
center. Coordination exists between these two centers because
respiration ceases for a fraction of a second when the airway closes
during the pharyngeal swallow. There is also cortical input to the
triggering of the pharyngeal swallow through the tongue-movement
patterns during the oral phase of the swallow.33 If triggering of
the pharyngeal swallow is delayed, none of these neuromuscular
activities occurs until the pharyngeal swallow is initiated. The
exact neurologic substrate for this cortical input is not clearly
understood.34
Pharyngeal Pressure Generation: Tongue-Base
Retraction and Pharyngeal Contraction
When the tail of the bolus reaches the base of the tongue, the
tongue base moves rapidly backward like a piston, increasing
1467
Soft palate
99
Tongue
Mandible
Vocal cords
pressure in the pharynx. As the tongue base moves backward, the
lateral and PPWs at the tongue-base level move inward. The
tongue base and pharyngeal walls should make complete contact.
Pharyngeal contraction, or the squeezing action of the constrictor
mechanism to move the bolus through the pharynx, occurs
sequentially, beginning in the superior constrictor muscle and
moving through the medial to the inferior constrictor muscle.30,35
Pharyngeal contraction is responsible for clearing material from
the pharyngeal walls and piriform sinuses. When residue or material
remains in the valleculae after the swallow, it is interpreted as a
symptom of reduced tongue-base movement.36
Airway Protection
Airway protection, as noted previously, involves two dimensions:
elevation and closure. Elevation is created by contraction of strap
musculature, which positions the larynx upward and forward under
the tongue base as it is retracted at the end of the oral phase of
the swallow. The larynx is pulled up and out of the way of the
passage of the food bolus over the base of the tongue. Closure of
the larynx involves three sphincters: the epiglottis and aryepiglottic
folds, the false vocal folds and airway entrance, and the true vocal
folds.31,37–40 The most important level of closure, airway entrance
closure, is maintained only for the fraction of a second that the
bolus is passing the airway.
Cricopharyngeal (Upper Esophageal
Sphincter) Opening
The cricopharyngeus muscle acts in opposition to the function of
the constrictor mechanism of the pharynx. At rest, the constrictors
are relaxed, and the cricopharyngeus muscle or UES is in tonic
contraction to prevent air intake into the esophagus concurrent
with inhalation into the lungs. The contracted cricopharyngeus
muscle also prevents backflow from the esophagus into the
pharynx.39 During the swallow, as the constrictor mechanism is
contracting, the cricopharyngeus muscle relaxes at the appro-
priate moment. The anterosuperior movement of the larynx
opens the UES, and the bolus passes into the esophagus. The
duration of UES opening and airway closure increases as bolus
volume increases.41
In summary, the pharyngeal stage of the swallow is responsible
for transit of material into the esophagus and for airway protec-
tion. Fig. 99.2 illustrates the progression of the bolus through
1468 PART VI Head and Neck Surgery and Oncology
Soft palate
Tongue
Mandible
Vocal cords
A B
D E
Fig. 99.2 (A–E) Lateral views of the head and neck illustrate the progression of a bolus through the pharynx.
the pharynx. If an anatomic or neuromuscular disorder affects
the pharyngeal stage of the swallow, poor bolus clearance and
airway invasion incorporating laryngeal penetration or aspiration
may result.
SIGNS AND SYMPTOMS OF ABNORMAL SWALLOW
ASSOCIATED WITH HEAD AND NECK CANCER
Impaired/Inefficient Swallowing (Dysphagia)
Impairment in swallowing function (dysphagia) has been commonly
associated with HNC, both as a presenting symptom and as a
sequela following treatment. Dysphagia associated with HNC
treatment (both surgical and nonsurgical approaches) can result
in deficits in the oral preparation, oral, pharyngeal, or esophageal
phases of swallowing. Additional negative consequences can arise
secondary to treatment toxicities such as mucositis, pain, trismus,
change in taste and appetite, and xerostomia. Presenting symptoms
of dysphagia may include coughing/choking when eating/drinking,
sensation of food sticking in the throat, excessive chewing, drooling
(sialorrhea), recurrent pulmonary complications/aspiration pneu-
monia, unintentional weight loss, and/or nutritional deficiencies.42
Physiological deficits of swallowing are related to tumor site
and size, and the treatment provided. These deficits can include
reduced lingual manipulation, control and propulsion of the bolus,
reduced tongue strength, impaired tongue base motion, delayed
C
triggering of the pharyngeal motor response, along with impaired
pharyngeal contraction, hyolaryngeal excursion, laryngeal closure
(vestibular and glottic), and cricopharyngeal opening.43–49 The
timing, control, and coordination of the swallowing mechanism
are also often impaired, resulting in reduced bolus clearance through
the oral cavity and pharynx, leading to food/fluid residue, along
with incomplete airway protection during the swallow.24,44–52 The
inability to safely and efficiently maintain a normal oral diet may
lead to significant negative lifestyle changes such as the need for
food/fluid modification, and/or nonoral feeding, which subsequently
impacts social eating and quality of life.53,54
Laryngeal Penetration and Aspiration
Laryngeal penetration (entry of food/fluid material into the
laryngeal vestibule above the level of the true vocal folds) and
aspiration (entry of food/fluid material into the airway below the
true vocal cords) are the potential negative consequences of
dysphagia. This can occur before, during, or after the pharyngeal
swallow.24 Airway invasion occurring before the pharyngeal swallow
can be caused by reduced tongue control during the oral preparatory
or oral stages of the swallow, allowing food/fluid to spill into the
open airway before the pharyngeal phase of the swallow is initiated.
Laryngeal penetration/aspiration during the swallow occurs if
airway closure is inadequate to prevent material from entering
the airway. This may result from a deficit at any level of closure
 CHAPTER 99 Swallowing Function and Implications in Head and Neck Cancer
(i.e., true vocal folds, false vocal cords, airway entrance, or the
epiglottis and aryepiglottic folds).24 Aspiration after the swallow
can occur from residue in the pharynx spilling into the airway.
Silent aspiration (where aspiration occurs without response, e.g.,
coughing, throat clearing) is a particular risk for patients with
deficits in pharyngeal or laryngeal sensation. Chronic aspiration
that is left untreated can contribute to long-term pulmonary
dysfunction and/or significant morbidity, particularly if aspiration
pneumonia ensues.55
EVALUATION OF SWALLOWING DISORDERS
Screening for Swallowing Disorders
A screening test may be primarily conducted to determine the
presence or absence of dysphagia, and inform the need for
referral for diagnostic assessment by a speech-language patholo-
gist (SLP) depending on facility-specific practices, established
screening protocols, if present, and providing adequate training
and instruction is implemented. Trained staff may complete a
facility-developed or standardized screening protocol (e.g., Toronto
Bedside Swallowing Screening Test).25,56–58 Swallow screening
protocols commonly involve identification of high-risk factors
(e.g., history of stroke), observation of oromotor and cognitive
abnormalities, and observation for clinical signs of aspiration (i.e.,
throat clearing or coughing) when swallowing small measured
amounts of liquid. Based on screening test results, the patient either
commences oral intake and medications or referral to an SLP is
initiated for a diagnostic swallowing assessment and treatment
as indicated.25,56–58
EVALUATION OF SWALLOWING
Referral to an SLP initiates a formal evaluation of oropharyngeal
swallowing function. Esophageal phase difficulties (without signs
of oropharyngeal dysphagia) are typically referred to the patient’s
treating medical team for investigation. Assessment by an SLP
typically commences with a clinical swallowing examination (CSE)
to examine dysphagia signs and symptoms, followed by instrumental
assessment to define the physiological cause of dysphagia and
inform clinical management.57,59
Clinical Swallow Examination
The CSE is conducted by an SLP and involves brief review of the
patient’s communication status followed by an oromotor assessment
involving evaluation of the motor and sensory components of
facial, lip, tongue, pharyngeal, and laryngeal function. Based on
these findings, food and fluids of varying consistency are trialed by
the patient to examine any obvious symptoms indicating impaired
efficiency or safety (i.e., coughing or throat clearing) during swal-
lowing. CSE results inform whether the patient is safe for oral
intake, guides diet/fluid recommendations, and assists with choice
and planning of instrumental assessment to further define swallow
pathophysiology and direct clinical management.60
Videofluoroscopy Swallow Study
Videofluoroscopy swallow study (VFSS) is a radiological procedure
that provides dynamic imaging of the upper aerodigestive tract
during all four stages of swallowing, beginning with the oral
preparatory phase and terminating with the esophageal phase.
The standard barium swallow or upper gastrointestinal procedure,
in contrast to VFSS, examines the anatomy and motility of the
esophagus and requires the patient to repeatedly swallow large
amounts of liquid barium, commonly in the supine position, to
evaluate esophageal peristalsis. VFSS is conducted to (1) define
oral and pharyngeal phase disorders; (2) identify the presence,
1469
99
Fig. 99.3 Lateral radiographic view during videofluoroscopic
evaluation of swallow or modified barium swallow study.
cause, and response to laryngeal penetration or aspiration occurring
before/during/after swallowing; (3) assess the effects of compensa-
tory strategies such as postural changes, sensory or food/fluid
texture modification, swallowing maneuvers; and (4) inform clinical
management and guide dysphagia rehabilitation. The VFSS
examination commonly begins in the lateral plane, framing the
lips anteriorly and the seventh cervical vertebrae inferiorly, which
enables complete viewing of oral and pharyngeal motility, airway
invasion and response, along with bolus transit into the upper
esophagus (Fig. 99.3). The anteroposterior plane enables viewing
of the symmetry of bolus flow through the oropharyngeal region,
but because the trachea overlies the esophagus, the assessment of
aspiration can be more difficult in this plane of view (Fig. 99.4).
An oblique view in the upright position often provides additional
valuable diagnostic information of both bolus transport through
the pharynx and into the proximal esophagus (Fig. 99.5). The
interrelationship between the oral-pharyngeal and esophageal
anatomical and physiological processes of swallowing is well
established. Therefore, during the VFSS, an esophageal screen or
a full esophagram (patient repositioned in right anterior oblique
view) should be conducted to identify contributions of possible
esophageal dysphagia. Food/fluid consistencies are mixed with
barium sulfate, and as the volume and delivery of oral trials is
controlled to limit aspiration risk, a VFSS is often recommended
over a barium swallow for patients with conditions at high risk
of oropharyngeal dysphagia, such as HNC, for adequate diagnosis
and management.36,61–74
Flexible Endoscopic Evaluation of Swallowing
Flexible endoscopic evaluation of swallowing (FEES) involves
placement of a flexible nasendoscope in the pharynx to directly
assess soft tissue anatomy and mucosa, laryngeal function, pha-
ryngolaryngeal sensitivity, and the pharyngeal phase of swallowing
(Fig. 99.6). Performed at the patient’s bedside or in clinic, FEES
assesses swallowing function using usual mealtime food and
fluids, or an ice chip protocol can be implemented to stimulate
swallow function in those patients at high risk of aspiration. It
examines the status and management of (1) oral secretions, (2)
food/fluid preswallow pooling/postswallow residue, and (3) airway
invasion both before and after swallow. During FEES, the oral and
1470 PART VI Head and Neck Surgery and Oncology
Fig. 99.4 Anteroposterior radiographic view during videofluoroscopic
evaluation of swallow or modified barium swallow study.
Fig. 99.5 Oblique radiographic view during videofluoroscopic
evaluation of swallow or modified barium swallow study.
Fig. 99.6 Flexible endoscopic evaluation of swallow image to
demonstrate a view of the hypopharynx/larynx post swallow of a thin
liquid bolus.
esophageal phases are not visualized and penetration/aspiration
cannot be viewed during the swallow due to approximation of the
tongue and pharynx against the tip of the nasendoscope, causing
“whiteout.” Using a direct view, FEES also informs and evaluates
compensatory swallow strategies and can serve as an effective
patient biofeedback tool to teach swallow rehabilitation. Given
the anatomical, sensory, and physiological changes associated with
HNC and its treatment, the portability and low-risk nature of this
exam means that FEES is commonly used and frequently repeated
to assess swallow impairment and guide dysphagia management
in the HNC population.75–77
Manometry
Manometry involves placement of a catheter containing pressure
sensors transnasally through the pharynx and esophagus to capture
pressure readings during liquid bolus swallows that are displayed
as waveforms with or without topographical plots.78 Traditionally
used to evaluate esophageal motility and upper and lower esophageal
sphincter, it is also gaining momentum in the quantitative analysis
of the pharyngeal phase of swallowing.79–81 Although low-resolution
pharyngeal manometry provides pressure analysis at three discrete
points, (1) the proximal pharynx at the tongue-base region, (2)
the distal pharynx at the laryngeal aditus, and (3) the region of
the UES, high-resolution manometry (HRM) uses 25 to 36 cir-
cumferential sensors and therefore enables continuous evaluation
of intraluminal pressure along the aerodigestive tract.82 Manometry
assesses the amplitude and duration of pharyngeal pressure, degree
of UES relaxation, and the coordination and timing of UES
relaxation relative to pharyngeal pressures. The addition of imped-
ance provides information about pressure flow analytics of the
swallow. Manometry with or without impedance can be performed
in conjunction with VFSS and is known as manofluroscopy, to
confirm sensor placement and examine swallow function while
limiting risk for those patients at high likelihood of aspiration.78,82
Manometry has been used to examine normal swallowing, disor-
dered swallowing seen in HNC and neurological populations, and
during swallowing maneuvers and alterations to fluid bolus texture
and volume.83–90 Although procedural limitations, such as catheter
instability/movement, technical expertise, and cost, have slowed
its application in clinical practice, manometry provides valuable
information on swallow biomechanics to support diagnosis and
guide therapeutic interventions, including medical treatments (e.g.,
Botox for cricopharyngeus dysfunction), choice of compensatory
 CHAPTER 99 Swallowing Function and Implications in Head and Neck Cancer
strategies and swallowing rehabilitation, and for biofeedback for
patient training.78,82
Ultrasonography
Ultrasonography is emerging as a noninvasive and inexpensive
examination to complement the more commonly used instrumental
swallowing assessments of VFSS and FEES. Ultrasonography has
been validated to measure muscle morphometry, particularly of
the tongue and submental muscles, and the kinematics of key
pharyngeal movements, in particular (1) superior-anterior-hyoid
displacement and (2) thyrohyoid approximation.82 Application
for the measurement of lateral pharyngeal wall placement, upper
esophageal sphincter opening, and airway invasion has also been
documented.91–93 With the patient in a seated position, a hand-
held or fixed transducer placement is applied against the skin
in the region of clinical interest: submental (oral cavity, floor of
mouth, tongue, hyomuscular region, palate, and upper pharynx);
neck (larynx, airway, and vocal cords); and along the side of the
neck near the ramus of the mandible (lateral pharyngeal wall).82,94
Information on the conductive properties of these tissues and
the relative distance from the transducer (using sound waves)
is used to create the ultrasound image, which is recorded for
analysis. Ultrasonography is beneficial in the HNC population
for examining changes in muscle composition over time for
inferring edema, fibrosis, and muscle atrophy after treatment and
evaluating swallowing function and changes when altering bolus
viscosity, volume, delivery (single versus continuous drinking),
and/or trialing compensatory swallow strategies. Easily repeat-
able and quantifiable, it can be conducted frequently to guide
swallow rehabilitation.82,94
SWALLOWING DISORDERS ARISING FROM HEAD
AND NECK CANCER TREATMENT
Dysphagia associated with HNC negatively impacts a patient’s
physiologic, functional, and psychosocial status. Surgery, radio-
therapy, chemotherapy, or a combination of these cause both
acute and chronic side effects, which may persist for months and
years. Some of these side effects contribute to long-term complica-
tions, such as osteoradionecrosis, deteriorating dentition, chronic
xerostomia, and surgical scarring and stricture. The psychosocial
impact of dysphagia on survivors of HNC is also multifaceted,
affecting socialization, family roles, and relationships.95 Early
intervention for dysphagia through targeted assessment and
rehabilitation is essential to optimize swallowing outcomes and
quality of life.24,96
Radiotherapy
Dysphagia is a well-recognized sequela following radiotherapy
treatment for HNC. Radiotherapy causes changes at a cellular
level, which leads to acute side effects such as pain, inflammation,
mucositis, and changes to taste and salivary function. These
symptoms can impact swallowing physiology as well as appetite
and desire to eat and drink. Chronic radiotherapy symptoms such
as xerostomia, fibrosis, trismus, and osteoradionecrosis can also
lead to an inability to manage a regular diet and fluids safely and
efficiently, and subsequently result in reliance on partial or total
alternative feeding for some patients.42 Technological advances in
radiotherapy treatment to limit swallowing dysfunction include
the identification and treatment contouring of key swallowing
structures and the use of new treatment technologies such
as intensity-modulated radiation therapy (IMRT), volumetric
modulated arc therapy (VMAT), and TomoTherapy, that deliver
highly conformal radiotherapy to targeted areas of disease, while
minimizing extraneous dose to surrounding structures.97–102 Research
to date is reporting variable results for swallowing function when
1471
using these new treatments, and therefore ongoing systematic
studies are required to document the long-term swallowing 99
outcomes associated with these treatments.97,99,103–108
Chemoradiation and Other Systemic Therapy
In recent years, the addition of concurrent chemotherapy or
epidermal growth factor receptor (EGFR) inhibitors to radiotherapy
protocols has been more commonly used due to their radiosensitizer
qualities resulting in improved locoregional control and overall
survival rates.109,110 The addition of these therapies has also
been recognized to increase local and systemic acute toxicity,
including dysgeusia, salivary dysfunction, dysphagia, and subsequent
weight loss.110,111
Acute chemoradiotherapy toxicity leads to local inflammation
of the swallowing musculature, altered oropharyngeal sensation,
and pain. Recent research has documented that the most commonly
occurring swallowing deficits following chemoradiotherapy for
HNC are delayed triggering of the pharyngeal swallow, reduced
hyolaryngeal excursion, tongue base dysfunction, reduced pha-
ryngeal contraction, and impaired epiglottic deflection.112 Such
altered swallowing physiology can result in incomplete airway
protection with swallowing and food and fluid residue in the
pharynx after swallowing, both of which can result in aspiration
risk. In severe cases, reliance on nonoral feeding via nasogastric
tube or gastrostomy is required.44,113,114 Research reports gastrostomy
use is common in patients receiving chemoradiotherapy, with
ongoing use required from 3 to 12 months after treatment, and
a high proportion of patients still requiring diet modification after
percutaneous endoscopic gastrostomy (PEG) removal.54,115 Over
the past decade, evidence has pointed to the benefits of providing
prophylactic swallowing therapy to patients receiving chemora-
diotherapy, with the aim of preventing the onset and impact of
severe and chronic dysphagia.8,54,116 These programs are commonly
delivered prior to and/or during treatment and offer an intense
regime of exercises that cover the jaw, tongue, and laryngeal and
pharyngeal function. Although the benefit of such programs has
been reported in early studies, ongoing research is being undertaken
to determine optimum treatment frequency, intensity, and dose.
Surgical Treatment
Surgical treatment for HNC can also significantly impact swal-
lowing with functional outcomes dependent on the site and extent
of disease, the surgical deficit, and the type of reconstruction.116
Sometimes patients who require complex surgical resections with
microvascular soft tissue and/or osteocutaneous flaps or prosthetic
obturation will have greater postoperative dysphagia when com-
pared to patients with small-scale, simple resections using primary
closure or healing by secondary intention. Changes in anatomical
structures, oropharyngeal sensation, and function can impact bolus
transit and control, swallow inefficiency, and postswallow residue,
leading to aspiration risk. Recent studies exploring the use of
transoral laser microsurgery (TLM) or transoral robotic surgery
(TORS) have described reduced length of stay, surgical defect and
complications, and improved swallowing outcomes.117–120 However,
further studies are required confirming the exact nature of swal-
lowing difficulties, and examining the long-term swallowing
outcomes following the use of these new surgical techniques.121
Anatomic Considerations
Treatment for HNC, particularly advanced disease, often involves
a number of structures within the oral and pharyngeal region.
Given the interconnectedness of the swallow process, consideration
of all anatomical areas/regions affected by treatment is required
to evaluate swallowing deficits and provide appropriate physiologi-
cally targeted dysphagia intervention. The following section
1472 PART VI Head and Neck Surgery and Oncology
provides an overview of the commonly occurring deficits in key
anatomical regions.
Oral Cavity/Tongue
Treatment for HNC tumors within the oral cavity/tongue can
cause significant changes to the oral preparation, oral, and pha-
ryngeal phases of swallowing. Common symptoms of swallowing
resulting from treatment to the oral cavity and tongue include
reduced oral containment and control, premature spillage of food/
fluid into the pharynx, oral and pharyngeal residue, delayed swal-
lowing trigger, and heightened risk of laryngeal penetration and
aspiration.122–124 Small oral cavity or tongue lesions, where surgical
resection can be managed with primary closure or small flap repair,
result in difficulty manipulating and cohesively preparing an oral
bolus ready for swallowing.125,126 Poorer swallowing outcomes are
observed in those patients requiring complex oral cavity/tongue
resection with reconstruction, characterized by reduced bolus
control, swallow inefficiency, and postswallow residue, with many
patients experiencing persistent aspiration risk at 12 months
postsurgery.122,124,125,127,128 Commonly, patients with large surgical
reconstructions with or without adjuvant treatment will require
diet/fluid modification with some becoming dependent on enteral
feeding.122,124,127
Oropharynx/Pharynx
Large HNC lesions involving the tonsil, retromolar trigone, base
of the tongue, or pharyngeal wall are commonly treated with
organ “preservation” treatments (i.e., chemoradiotherapy) due to
the significant functional morbidity that results following extensive
open surgical resection of this region.129–131 Transoral approaches
have, however, changed the paradigm and in many instances may
result in excellent swallowing with such large lesions, especially
in the HPV-mediated tumor era.
For lesions of the oropharynx that are suitable for resection with
flap reconstruction, surgery can impact both sensory and motor
functions, with (initially) insensate free flap repair affecting bolus
control, swallow efficiency, and airway protection, and postswallow
residue.122–125 Swallowing disorders following surgical treatment for
oropharyngeal cancer include impaired oral preparation/control,
delayed swallow trigger, poor velopharyngeal closure resulting in
nasal regurgitation, reduced tongue base–to–PPW approximation,
and reduced pharyngeal contraction leading to postswallow residue
and aspiration risk.6,14,122–125,127 Food/fluid texture modification and/
or compensatory strategies are commonly used to support safe
swallowing and improve swallow efficiency.122,124,127 Curative-intent
chemoradiotherapy to the oropharyngeal and pharyngeal region
results in acute and localized edema, pain, mucositis, and impaired
sensation, commonly leading to odynophagia, and chronically,
later, poor pharyngeal contraction/clearance, poor awareness of
pharyngeal residue, and/or laryngeal penetration/aspiration.6,14
As with large oral cavity/tongue lesions, patients treated with
complex oropharyngeal surgery and/or chemoradiotherapy com-
monly require diet/fluid modification with some requiring enteral
nutrition support long term.122,124,127
Larynx/Hypopharynx
Dysphagia is a common sequel to large tumors arising from the
larynx and hypopharynx, due to the close proximity of the airway
protection structures. Surgical resection and/or (chemo)radiotherapy
for disease located in the larynx/hypopharynx can negatively affect
swallowing function due to impacts on hyolaryngeal excursion,
laryngeal closure at the supraglottis and glottis, pharyngeal clear-
ance, and UES opening.55 Partial laryngeal surgery (i.e., hemilar-
yngectomy, supraglottic laryngectomy, supracricoid laryngectomy)
has become less common over the past decade due to its negative
functional outcome. Postoperatively, patients commonly present
with heightened aspiration risk, poor tolerance of oral secretions
requiring tracheostomy placement, and dependence on non-oral
feeding. Depending on the degree of resection and nature of
reconstruction, many patients regain their swallowing function
after an intense period of swallow rehabilitation.96,132–136 However,
“inside-out,” transoral resections, usually TLM, have endowed
faster swallowing rehabilitation than many open partial laryngeal
procedures, due to their avoidance of a tracheostomy and obviation
of the need to dismantle the musculoskeletal structure of the
larynx. An exception is the supracricoid laryngectomy, which
incorporates cricohyoidpexy for reconstruction, in which the
majority of patients swallow remarkably well.
Extensive resections like those required for larger cancers of
the larynx/hypopharynx, such as total laryngectomy or pharyn-
golaryngectomy, ameliorate the risk of aspiration due to the
permanent surgical separation of the trachea and esophagus.
Aspiration remains a risk for those patients who undergo surgical
voice restoration where a puncture is created between the posterior
tracheal wall and the esophagus for the placement of a tracheo-
esophageal voice prosthesis. Following laryngectomy and pharyn-
golaryngectomy, efficient bolus flow can be affected by a reduction
in tongue base and/or pharyngeal/neopharynx pressures, changes
in structure/obstruction (e.g., reduced pharyngeal width, pseudo-
epiglottis), and changes to esophageal motility.50,137–139 With
pharyngolaryngectomy, the type of free flap and location of
reconstruction can further impact the degree and nature of dys-
phagia. Laryngeal and hypopharyngeal tumors treated nonsurgically,
with organ perseveration intent, can result in a severe dysphagia,
due to the acute and chronic side effects on pharyngeal and laryngeal
function. Localized edema and lymphedema, pain, atrophy, and
especially stricture/stenosis affecting base-of-tongue retraction,
epiglottic retroflexion, laryngeal closure, pharyngeal contraction,
cricopharyngeal opening, and sensation can result.14,114,140–145 Given
the significant morbidity that can occur, functional swallow
preservation, alongside organ preservation, in these cases needs
careful consideration.
POSTTREATMENT COMPLICATIONS
Technological advances have created improved treatments for
patients with HNC, a shift in demographic profile to include a
majority of HPV-mediated disease, and the delivery of prophylactic
swallowing therapy and expert supportive care has meant improved
survival, locoregional control, and management of dysphagia for
this group. Patients are living longer with the side effects of their
disease and treatment. Long-term complications can include
physical worsening of side effects including the onset of osteora-
dionecrosis, deteriorating dentition, chronic xerostomia, and surgical
scarring, fistula, stenosis, and stricture. The psychosocial impact
of dysphagia on survivors of HNC is multifaceted, affecting
socialization, family mealtimes, relationship functioning, and return
to family and community roles.95
SUMMARY
Dysphagia, or swallowing difficulty, and aspiration are generic terms
for problems that have a number of specific anatomic or physiologic
causes. Swallowing difficulties in patients with head and neck
cancer following surgical and nonsurgical treatment require accurate
identification of the structural and physiological reason(s) for the
swallowing impairment and risk of aspiration. Each of the known
causes of aspiration—delayed triggering of the pharyngeal swallow,
and reduction in tongue control, laryngeal closure, laryngeal
elevation, tongue-base retraction, and pharyngeal contraction—all
require a different treatment approach. The best available proce-
dures should be used to assess the patient’s swallowing physiology
and anatomic/structural changes, and the findings should be
 CHAPTER 99 Swallowing Function and Implications in Head and Neck Cancer
compared with normal data. Currently, a videofluoroscopic pro-
cedure (VFSS) or modified barium swallow (MBS) study gives
valuable results for determining the swallowing physiological
impairment(s), structural changes, and the assessment of airway
protection to identify potential aspiration and its cause. The other
techniques for assessment of swallowing, which include clinical
swallow evaluation, pharyngeal and esophageal manometry,
ultrasonography, and FEES, as with the VFSS, provide valuable
diagnostic information to further assess the swallowing impairment
(e.g., physiological and structural) and the effectiveness of treat-
ments. FEES, pharyngeal manometry, and ultrasonography are
also used beyond the diagnostic model for visual biofeedback and
training on therapeutic techniques/exercises and compensatory
swallow strategies to improve the patient’s functional outcome.
Patients undergoing radiation with or without chemotherapy
as the primary treatment should be assessed at baseline and followed
during treatment for prophylactic swallow intervention and followed
long term, as indicated, in a systematic and multidisciplinary team
(MDT) approach. Surgical patients undergoing postsurgical chemo
therapy and/or radiation should be followed by the speech patholo-
gist in the same manner during and after treatment. Optimum
diagnostic evaluation and treatment planning of a patient with a
swallowing disorder involves an instrumental examination (e.g.,
VFSS and/or FEES) to determine treatment strategies and oral
1473
diet level advancement to ensure the patient can safely tolerate
the least restrictive diet to maintain adequate nutrition and hydra- 99
tion. Recommendations should include a thorough review of the
patient’s medical status and ongoing communication and coordina-
tion with the MDT, including the head and neck surgeon,
reconstructive surgeon, medical and radiation oncologist, dietitian,
nursing, and other members of the team. With appropriate
diagnostic assessments, the patient’s treatment plan should be
developed, including consideration of diet advancement to as
normal a diet as possible, so potential complications from chronic
aspiration, malnutrition, or dehydration may be avoided.
A speech pathologist who specializes in the diagnosis and
treatment of swallowing disorders in HNC must be involved in
the patient’s treatment from the time that HNC is diagnosed so
that timely evaluation and management of swallowing disorders
may be initiated, and as much normal function as possible may
be restored and/or preserved in the shortest postsurgical and
treatment time period. This requires a vigilant and proactive
approach to meet the changing demands of patients and the
multidisciplinary team (MDT). Using an MDT approach with
the speech pathologist as an active member of the team is essential
in HNC management.
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