Bolus effects on patient awareness of swallowing difficulty and swallow physiology after...

Title: Bolus Effects on Patient Awareness of Swallowing Difficulty and Swallow Physiology following

Chemoradiation for Head and Neck Cancer

Authors:

Nicole M. Rogus‐Pulia, PhD, CCC‐SLP

Women's Health Postdoctoral Fellow

William S. Middleton Memorial Veterans Hospital

Adjunct Professor, University of Wisconsin‐Madison

Department of Medicine, School of Medicine and Public Health

Speech, Swallowing, And Dining Enhancement Program

2500 Overlook Terrace

Madison GRECC (11G), Room D5216

Madison, WI 53705

Margaret Pierce, RN, BSN, OCN

Nursing Clinical Coordinator

Radiation Oncology

Northwestern Memorial Hospital

Chicago, IL, 60611

Bharat B Mittal, MD

Professor and Chairman, Department of Radiation Oncology

Northwestern University

Feinberg School of Medicine

Chicago, IL, 60611

Steven G. Zecker, Ph.D.


This article has been accepted for publication and undergone full peer review but has not beenthrough the copyediting, typesetting, pagination and proofreading process which may lead todifferences between this version and the Version of Record. Please cite this article as an‘Accepted Article’, doi: 10.1002/hed.23720

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Department of Communication Sciences and Disorders

Frances Searle Building

Evanston, IL 60208

Jeri Logemann, PhD, CCC‐SLP


Department of Communication Sciences and Disorders

Frances Searle Building

Evanston, IL 60208

Please send reprints to:

Nicole M. Rogus‐Pulia

William S. Middleton Memorial Veterans Hospital

2500 Overlook Terrace

Madison GRECC (11G), Room D5216

Madison, WI 53705

Phone: 708‐699‐8615

Acknowledgments: The authors would like to thank Muveddet Harris for assistance with data reduction;

Kristin Larsen, Sharon Veis, Cory Atkinson, and Megan Schliep for assistance with subject recruitment;

and Charles Larson for editorial feedback. This manuscript was partially prepared within the Geriatric

Research Education and Clinical Center (GRECC) at the William S. Middleton Veteran Affairs Hospital in

Madison, WI; GRECC manuscript ####. The views and content expressed in this article are solely the

responsibility of the authors and do not necessarily reflect the position, policy, or official views of the

Department of Veteran Affairs or U.S. government.

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Presentations: The results of this study were presented at the American Speech‐Language‐Hearing

Association Annual Convention in Atlanta, Georgia on November 17th, 2012.

Running title: Bolus Effects on Swallowing in Head and Neck Cancer Patients

Key words: dysphagia, chemoradiation, head and neck cancer, perception, bolus, volume, consistency

Conflicts of interest: The authors have no conflicts of interest to declare.

Abstract:

Background: Patients treated for head and neck cancer frequently develop dysphagia. Bolus

characteristics are altered during fluoroscopic swallowing studies to observe the impact on swallowing

function. The purpose of this study was to determine bolus volume and consistency effects on

oropharyngeal swallowing physiology and patient awareness of swallowing difficulty.

Methods: 21 patients with head and neck cancer were assessed pre‐ and post‐chemoradiation. The

Modified Barium Swallow Study was utilized to examine swallow physiology. Each subject provided

perceptual ratings of swallowing difficulty after each swallow of varying bolus types.

Results: Oral transit times were significantly longer with pudding boluses. There were trends for higher

residue percentages as well as perceptual ratings for pudding and cookie boluses. One correlation

between perceptual ratings and physiology was significant.

Conclusions: Patient awareness of swallowing difficulty and aspects of swallowing physiology vary with

bolus consistency. Patient awareness does not correlate with observed changes in swallowing

physiology.

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Introduction

Patients with head and neck cancer who receive chemoradiation treatment frequently develop

dysphagia as a result of radiation‐induced fibrosis to the critical tissues and damage to the

neuromuscular junctions of the head and neck region1–9. Changes in bolus size and consistency along

with postural changes may be effective in eliminating aspiration, the most dangerous complication of

dysphagia 2,10. In clinical practice, bolus volume and/or consistency is often altered in order to observe

effects on swallow physiology.

Systematic changes in normal swallowing with increasing bolus volume have been well‐

documented10–19. With increasing viscosity of the bolus, various changes in the normal swallow have

also been observed10,11,13,20,21. Alterations in swallow physiology that occur in response to changes in

bolus volume and viscosity have also been documented in patients with various medical conditions that

often lead to dysphagia10,22. Trends observed across all of these patient groups, including patients with

head and neck cancer, can be summarized as higher rates of aspiration with thin liquids4,6,22, increased

residue with larger volume and pudding boluses23, higher generated tongue pressure with increased

volume and viscosity24–26, and improved pharyngeal delay time (when bolus first enters pharynx until

laryngeal elevation begins) with larger volumes15,27. Limitations of these previous studies include a

limited number of bolus types and presentation of boluses in a traditional hierarchy of increasing

volume and viscosity. As swallowing is a neuromuscular function that is susceptible to fatigue effects 28–

30, the potential influence of bolus presentation order on oropharyngeal swallow physiology during the

Modified Barium Swallow Study (MBSS) requires consideration. To mitigate any potential confounding

impact, a randomized order of bolus presentation was utilized in this study.

The type of bolus swallowed may not only affect swallow physiology but may also affect patient

awareness of swallowing difficulty31. One study by Pauloski et al31 examined agreement between

patients’ complaint of dysphagia and actual swallowing function. The results of this study indicated that

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patients with head and neck cancer treated with chemoradiation were able to accurately perceive

decreases in their swallowing function. Results also suggested that patient awareness of swallowing

difficulty may vary with bolus type but this was not specifically examined.

A broader understanding of how awareness of swallowing as well as swallow physiology

changes with bolus type in patients who receive chemoradiation for head and neck cancer is both

necessary and clinically useful. This information may allow for more informed expectations prior to

swallow assessment, more accurate diet recommendations, and improved patient compliance with

recommendations. The purpose of this study was to determine whether bolus type influences

physiology of the oropharyngeal swallow or awareness of swallowing difficulty in patients treated for

head and neck cancer with chemoradiation. Within this larger purpose, there were two specific aims.

First, we set out to determine how measures of swallow physiology would change depending upon the

type of bolus given to the patient. We hypothesized that measures of swallowing physiology would be

significantly worse (longer transit times and higher amounts of residue) for more viscous and thicker

boluses than for thinner or less viscous boluses regardless of volume. Second, we wanted to observe

whether patient awareness of swallowing ability varied depending upon bolus type. The hypothesis to

be tested was that patients would report higher ratings of swallowing difficulty as viscosity (liquid

boluses) and thickness (pudding and cookie boluses) increased, regardless of bolus volume.

Materials and Methods

Subjects

There were 21 patients diagnosed with head and neck cancer and treated with chemoradiation

treatment. Patients were recruited through referrals from cooperating radiation oncologists, medical

oncologists, and head and neck surgeons at Northwestern Memorial Hospital.

The patients consisted of individuals from 36 to 80 years of age (average age of 56 years) (see

Table 1 for patient characteristics). These patients were diagnosed with oral, oropharyngeal,

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nasopharyngeal, or laryngeal tumors (see Table 2) and were treated with a full course of radiotherapy

and chemotherapy. All patients received at least 60 Gy over an average of 7 weeks. Five of the twenty‐

one patients received induction chemotherapy followed by concurrent chemoradiation. The other

sixteen patients received concurrent chemoradiation only. Eight of the patients received surgical

intervention (partial glossectomy, tonsillectomy, or neck dissection) followed by post‐operative

chemoradiation. The radiation delivery was intensity‐modulated for all the patients but one who

received conventional external‐beam radiation (see Table 1). Inclusion criteria for the patient group

were 1) diagnosis of head and neck cancer by a medical doctor and 2) planned total radiation dosage of

at least 50 Gy with concurrent chemotherapy. Exclusion criteria were 1) other medical problems known

to cause salivary gland hypofunction32 and/or dysphagia (e.g., neurological problems, gastroenterologic

problems, etc), 2) prior swallowing treatment, and 3) prescribed medication that could affect

swallowing.

Study Procedures

The protocol was approved by the Institutional Review Board of Northwestern University, and

all subjects signed informed consent statements. Each patient was evaluated twice, once prior to

initiation of chemoradiation treatment and once after completion of treatment. The pre‐treatment

assessment point took place an average of 3.5 weeks before treatment began. The post‐treatment

assessment for the majority of patients was between 3 months and 1 year post‐treatment (an average

of 5 months). Three patients were up to two years post‐treatment due to difficulty with follow‐up. Data

collection at each assessment point consisted of a MBSSand questions related to patients’ awareness of

difficulty swallowing.

Modified Barium Swallow Study

Each subject’s swallowing was examined using a MBSS. MBSS enables visualization and

measurement of the critical movements of the oropharyngeal swallow. Each subject was administered

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two boluses of each of the following consistencies: 1 and 10 ml of thin liquid barium, 3 and 10 ml of

nectar thick liquid barium, 3 ml of thin paste (67% vanilla pudding and 33% EZ EM barium paste), 3 ml of

standard barium paste; and ¼ of a Lorna Doone cookie covered with 1 ml of EZ EM barium paste. All

swallows were viewed in the lateral plane. All bolus volumes were measured by syringe and gently

placed into the patient’s mouth either via syringe or spoon. The patient was instructed to hold the bolus

in his/her mouth until directed to swallow.

The specific bolus types chosen for inclusion in this study were based on the goal of

representing a wide variety of both bolus volumes and viscosities/thicknesses while limiting the total

number of boluses administered for radiation safety. The order of presentation of these varying boluses

was randomized in order to avoid any order effects, such as fatigue, that may occur. The order of

presentation was the same at both assessment points so that changes in swallow physiology for

particular bolus types post‐treatment could be more accurately attributed to effects of chemoradiation.

If a patient aspirated greater than 5% of the bolus on the first swallow of a given bolus type, the second

swallow of this bolus type was not administered.

Data Reduction

Two types of measures and observations were made from fluoroscopic recordings: 1)

approximate amount (percentage) of residue as well as instances of penetration and aspiration and 2)

selected temporal measurements of structural and bolus movement. MBSS data were recorded on 1/2

inch videotape. The measures and observations were made through visual inspection of the recordings

at regular speed, slow motion, and frame‐by‐frame using a DVC‐PRO machine. Ten percent of all

swallows were reanalyzed by the same observer as well as by a different observer to determine

intrajudge and interjudge reliability. Pearson correlation coefficients of intrajudge and interjudge

reliability were high (.95‐.99) for all measures.

Approximate percent residue and instances of penetration and aspiration

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The only instrumentation that enables quantification of residue is scintigraphy, a nuclear

medicine test involving swallows of measured amounts of a radioactive substance. Data from previous

studies examining the correlations between oral residue measure from scintigraphy33 and estimations of

amount of oral residue from the modified barium swallow indicate that observations of approximate

percent residue from videofluoroscopy can be accurate when done by well‐trained staff 34. The

presence or absence as well as the amount of residue in the oral and pharyngeal cavities were

determined. The number of instances of penetration and aspiration at different time points (before,

during, or after the swallow) were recorded.

Temporal Analysis of Bolus Movement

Using frame‐by‐frame analysis and slow motion, videoframes on which the bolus reached

specific points in the oropharynx and when particular structural movements began and ended were

identified. The recordings were captured at 30 frames per second (60 fields per second). The following

events were recorded: (a) first backward movement of the bolus (defined as the onset of oral transit);

(b) head (leading edge) of the bolus reaches the point where the ramus of the mandible crosses the

tongue base(the point by which the pharyngeal swallow should trigger); (c) beginning of laryngeal

elevation (first elevation associated with the onset of the pharyngeal stage of the swallow; the arytenoid

cartilages and/or true vocal folds were used as structural landmarks for this measure); (d) end of

cricopharyngeal opening (the tail of the bolus leaves the cricopharyngeal region, defined as the

termination of the pharyngeal swallow).

From these events, the following durational measures were made: oral transit time (OTT, b‐a)‐ the time

it takes the bolus to move through the oral cavity; pharyngeal delay time (PDT, c‐b)‐ the time from bolus

head passing the posterior edge of the ramus of the mandible until the initial observation of laryngeal

elevation; pharyngeal response time (PRT, d‐c)‐ the time from the onset of laryngeal elevation until the

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bolus tail passes through the cricopharyngeal sphincter; and pharyngeal transit time (PTT, d‐b)‐ the time

required for the bolus to move through the pharynx. Patient Awareness of Swallowing by Bolus Type

Following every swallow during the MBSS, each subject was asked to provide a rating of how

difficult the particular bolus was to swallow. Subjects were asked to indicate a number from 1 to 7 with

1 representing no difficulty with swallowing and 7 representing the most severe difficulty with

swallowing..

Statistical Analysis

Values for each dependent variable (percentages of residue, instances of

penetration/aspiration, durational measures and perception ratings) were averaged across trials to

obtain one value per bolus type. A two‐way repeated measures ANOVA with independent variables of

time (changes from pre‐ to post‐treatment) and bolus type was performed for each dependent variable.

A repeated measures ANOVA was also conducted at the post‐treatment point to determine differences

in the dependent variables based on bolus type alone. Changes in the number of penetration and

aspiration instances from pre‐treatment to post‐treatment were determined using McNemar’s exact

test. Pearson product‐moment correlation coefficients were calculated to examine relationships

between perception per bolus type and the measures of physiology for each bolus type. If a subject had

missing data, which did occur for temporal data on less than 5% of the swallows due to difficulties with

equipment or the image, then missing data specific to each analysis were excluded from that particular

analysis.

Correlations between the demographic variables of continuous nature (age, radiation total dose,

time to pre‐treatment assessment, time to post‐treatment assessment) and the dependent variables in

this study were also calculated at both pre‐treatment and post‐treatment. Since there were no strong

correlations present, these variables were not included as covariates in the analyses. Despite several

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patients with post‐treatment evaluations further out from treatment completion, the time to post‐

treatment assessment variable did not appear to influence results.

Results

Pre‐treatment to Post‐treatment Comparison

These comparisons allowed for examination of changes in percentages of residue, instances of

penetration/aspiration, durational measures and perceptual ratings from pre‐ to post‐treatment and

whether these changes were dependent upon the type of bolus being swallowed.

Measures of Swallow Physiology

Pharyngeal response time was the only durational measure that was found to be significantly

longer following treatment. Two‐way repeated measures ANOVA revealed a main effect for time

(F(1,13)=4.87, p<.05) indicating longer pharyngeal response times across all bolus types post‐treatment.

There were no interactions or main effects present for the other individual durational measures (OTT,

PDT, PTT).

Regardless of bolus type, a higher percentage of the bolus remained in both the oral

(F(1,15)=18.94, p<.002) and pharyngeal (F(1,16)=10.39, p<.01) cavities after the swallow in the patients

post‐treatment as compared to pre‐treatment. There was a trend observed for higher percentages of

oral and pharyngeal residue with pudding and cookie boluses as compared to other bolus types at the

post‐treatment point (see Figures 1 and 2).

The incidence of penetration increased for certain bolus types after treatment while the

incidence of aspiration did not change significantly. McNemar’s exact test revealed significantly more

instances of penetration post‐treatment for the 10mL thin liquid boluses (p<.03) and the 3mL nectar‐

thick boluses (p<.03). There were no significant changes for the other bolus types. All instances of

penetration both pre‐ and post‐treatment were “silent” (no throat clear or cough in response). There

were no instances of aspiration pre‐treatment, but 89% (8/9) of aspiration occurrences post‐treatment

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also were “silent”. The one occurrence of aspiration for which a patient coughed in response was on a

3mL nectar‐thick liquid bolus (see Table 3 for the incidence of penetration and aspiration by bolus type).

Patient Awareness of Swallowing by Bolus Type

Patient ratings of swallowing difficulty did not vary significantly based on bolus type or time

relative to treatment. The two‐way repeated measures analysis of variance revealed no interaction

effect for bolus type by time (F(6,15)= 1.93, p=.436) or main effect for time (F(1,20)=.147, p=.706).

However, there was a trend for ratings of swallowing difficulty to be higher on paste and cookie boluses

as compared to all of the liquid bolus types at the post‐treatment assessment point (see Figure 3).

Post‐treatment Comparison based on Bolus Type:

These comparisons allowed for examination of differences between bolus types for percentages

of residue, instances of penetration/aspiration, durational measures and perception ratings at the post‐

treatment assessment point.

Measures of Swallow Physiology

Oral transit time and pharyngeal delay time were the durational measures found to vary

significantly with bolus type at the post‐treatment assessment point. A significant main effect for bolus

type was found for oral transit time (Wilks lambda= .295, F(6,11)= 4.37, p<.02). Post‐hoc analyses

revealed that oral transit time was significantly longer for pudding boluses as compared to 1mL thin

liquid, 10mL thin liquid, 3mL nectar‐thick liquid, 10mL nectar‐thick liquid. Oral transit time was

significantly shorter for cookie boluses as compared to 1mL thin liquid, 10mL nectar‐thick liquid, thin

pudding, and standard pudding boluses.

A significant main effect for bolus type also wasfound for pharyngeal delay time (Wilks lambda=

.245, F(6,10)= 5.13, p=.012) with significantly shorter PDTs for cookie boluses as compared to all other

bolus types. There were no significant effects for pharyngeal response time or pharyngeal transit time.

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There were no significant effects for bolus type for the oral and pharyngeal residue levels or instances of

penetration or aspiration.

Patient Awareness of Swallowing by Bolus Type

At the post‐treatment point, awareness of swallowing difficulty did not differ between bolus

types. A repeated measures ANOVA showed no significant effect for bolus type (Wilks’ lambda= .501,

F(6,15)= 2.49, p=.071).

Correlations between Perception and Physiology by Bolus Type

No significant correlations were found between patient awareness ratings and the following

measures: oral residue, OTT, PRT, PDT, or PTT. For the pudding bolus only, there was a moderate,

positive correlation between percentage of pharyngeal residue and the awareness rating (r=.508, p<.02;

see Table 4). As amount of pharyngeal residue increased on pudding boluses, patients perceived more

difficulty swallowing the pudding.

Summary of Results

In summary, results revealed longer pharyngeal response times as well as more residue in the

oral cavity and pharynx after treatment for all bolus types. There were higher incidences of penetration

on 10mL thin liquid and 3mL nectar‐thick liquid boluses after treatment. Patient perception of

swallowing difficulty did not change significantly following treatment despite documented worsening of

swallowing function as stated above. However, there were trends for slightly higher ratings on pudding

and cookie boluses after treatment. After treatment, oral transit time was longest for pudding boluses

and shortest for cookie boluses. Pharyngeal delay time was shortest for cookie boluses after treatment.

There was only one significant correlation between patient awareness ratings and measures of swallow

physiology by bolus type.

Discussion

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The focus of this study was to clarify whether changes in measures of swallow physiology and

patient awareness of swallowing difficulty following chemoradiation treatment are dependent upon the

type of bolus swallowed. Increased amounts of residue in the oral cavity and pharynx as well as longer

pharyngeal response times post‐treatment occurred across all bolus types. When comparing bolus

types, there were significantly longer oral transit times for pudding boluses as well as trends towards

higher amounts of residue and patient ratings of swallowing difficulty for pudding and cookie boluses.

By randomizing the order of bolus presentation, the results observed could be more accurately

attributed to variations in swallowing related to bolus type rather than to potential fatigue effects.

The higher percentages of residue observed in the oral cavity and pharynx along with longer

pharyngeal response times following treatment could reflect fibrosis of the head and neck musculature

resulting in reduced strength and therefore poor pharyngeal constriction. This may lead to more

difficulty clearing the pharynx during the swallow. The role of salivary gland hypofunction32 resulting

from inclusion of salivary glands in the radiation field also may contribute to increased amounts of

residue. Decreased production of saliva (hyposalivation) may result in less coating of oral and

pharyngeal structures as well as poor lubrication of the bolus that becomes critical to transport.There

were significantly longer oral transit times at the post‐treatment point for pudding boluses as compared

to multiple liquid bolus types. These changes could be due to known fibrosis‐related decreases in

lingual strength following chemoradiation treatment3,35–37. They also may be related to salivary gland

hypofunction resulting in poor lubrication which could impact the transport of viscous boluses to a

greater degree. However, the oral transit times for cookie boluses, not including mastication times,

were found to be significantly shorter as compared to multiple liquid boluses and pudding boluses. This

unexpected finding could be related to possible stimulation of saliva which occurs during mastication

and may improve bolus transport in patients with salivary gland hypofunction. Also, oral transit time

reflects duration of bolus transit through the oral cavity and into the pharynx following completion of

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mastication. Future research should include an additional measure of oral preparation or mastication

time as this may be prolonged in patients following treatment due to salivary gland hypofunction and/or

reductions in lingual strength.

In addition, pharyngeal delay times that reflect the timing of the pharyngeal response were

shorter for cookie boluses. This was again an unexpected finding considering that typically, while

chewing, some of the bolus moves into the vallecular space. This finding reflects the way cookie

boluses were analyzed during frame‐by‐frame analysis of videofluoroscopic recordings. When

determining pharyngeal delay time, the arrival of the bolus into the pharynx was considered as it relates

to initiation of the oral transport during the swallow and not entry into the vallecular space during

chewing. It is also possible that the additional sensory stimulation provided by the process of

mastication may explain quicker triggering of the swallow with cookie boluses.

Findings of increased frequency of penetration during the swallow for 10mL thin liquid and 3mL

nectar‐thick boluses is consistent with findings by Daggett et al38 who reported a lower incidence of

penetration with non‐liquid (and thicker) consistencies in normal subjects. The lower frequencies of

penetration with the higher (10mL) volume nectar‐thick bolus type as compared to a lower volume

(3mL) nectar‐thick bolus type conflict with previous research findings that suggest more frequent

occurrences of penetration with increased bolus volumes38. It may be that the combination of a larger

and slightly thicker bolus (as compared to thin liquid) provided increased sensory input during the

swallow that resulted in improved airway protection. This emphasizes the clinical need to examine the

effect of thickened liquids in these patients since one cannot assume that thickened liquids will continue

to reduce penetration without examining their effect across volumes. Although the increase in number

of aspiration occurrences post‐treatment was non‐significant, the majority of occurrences were “silent”

(no throat clear or cough in response). These findings reflect sensory deficits that result in decreased

patient awareness and support the concern over “silent” aspiration in this patient population. Although

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non‐significant, there were trends towards higher amounts of oral and pharyngeal residue for pudding

and cookie boluses than for other bolus types at the post‐treatment point. This is consistent with

previous work showing higher levels of residue for thicker boluses39–41. Another non‐significant trend,

towards higher patient ratings of swallowing difficulty for pudding and cookie boluses, also was

observed. It is possible that, with a larger sample size, the relatively larger increases in percentages of

residue and perception ratings observed with pudding and cookie boluses would reach significance.

There were several limitations to this study. Patients with head and neck cancer varied in terms

of tumor site and location as well as size of radiation field, exact chemoradiation treatment protocol,

and smoking or alcohol history. A subset of the patients received some type of surgical intervention

followed by chemoradiation. Due to varying types of surgery (tonsillectomy, partial glossectomy, and

neck dissection) and the small number of patients in this category, it was not possible to determine

differential effects of specific types of surgery followed by chemoradiation versus chemoradiation alone.

This is an important area for future research with a larger overall sample size. The time from completion

of treatment to post‐treatment assessment varied in our patient group as well. Due to difficulty with

follow‐up closer to treatment completion secondary to acute effects, several patients were assessed at a

later point as compared to the rest of the group.

Despite non‐significant trends of higher patient perception ratings and amounts of residue with

pudding and cookie bolus, only one correlation between percentages of pharyngeal residue and patient

perception ratings for a pudding bolus was significant. If patient awareness of swallowing closely

reflects changes in swallow physiology, more positive correlations would be expected. Therefore, the

lack of significant correlations observed in this study suggests some level of disconnect between patient

awareness of swallowing and swallowing function. Pauloski et al31 reported general agreement between

perception and physiology for multiple bolus types; however, perceptions of swallowing difficulty in this

study were not bolus‐specific. When patients were asked to rate difficulty of swallowing for each bolus

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type in our study, this consistent level of agreement was not observed. Overall, patient ratings of

difficulty were low (<3). It may be that patients do not observe as much difficulty swallowing as would

be expected from the observed changes in swallowing physiology. This relatively poor awareness of any

swallowing difficulty may be the reason patients often continue to swallow foods that are not safe or

efficient for them. Future research should focus on other potential mediating factors of this relationship

between patient awareness of swallowing difficulty and physiology, such as salivary hypofunction and

oropharyngeal sensation.

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27. Logemann JA, Pauloski BR, Colangelo L, Lazarus C, Fujiu M, Kahrilas PJ. Effects of a sour bolus on oropharyngeal swallowing measures in patients with neurogenic dysphagia. J Speech Hear Res. 1995;38(3):556–563.

28. Kays SA, Hind JA, Gangnon RE, Robbins J. Effects of dining on tongue endurance and swallowing‐related outcomes. J Speech Lang Hear Res. 2010;53(4):898–907.

29. Roy N, Stemple J, Merrill RM, Thomas L. Dysphagia in the elderly: preliminary evidence of prevalence, risk factors, and socioemotional effects. Ann Otol Rhinol Laryngol. 2007;116(11):858–865.

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31. Pauloski BR, Rademaker AW, Logemann JA, et al. Swallow function and perception of dysphagia in patients with head and neck cancer. Head Neck. 2002;24(6):555–565.

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33. Holt S, Miron SD, Diaz MC, Shields R, Ingraham D, Bellon EM. Scintigraphic measurement of oropharyngeal transit in man. Dig Dis Sci. 1990;35(10):1198–1204.

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40. Pauloski BR, Logemann JA, Rademaker AW, et al. Speech and swallowing function after oral and oropharyngeal resections: one‐year follow‐up. Head Neck. 1994;16(4):313–322.

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Table 1: Demographic variables and treatment details for all patients

*Radiation Treatment, †Chemotherapy, ‡Y=Yes; N=No, §M=Male, F= Female, ǁT=tumor, N=node, M=metastasis

¶Specific chemotherapeutic agents were unavailable in this patient’s electronic medical record due to treatment provided by an outside hospital.

Subject Age Sex Tumor Site Tumor Stage

Total RT* dose

Induction Chemo† (Y/N‡)

Concurrent Chemo† (Y/N‡)

Chemo Drugs Administered

Surgery Smoking/ Alcohol Abuse

1 36 M§ Nasopharynx T2bN3bM0

ǁ 70 Gy Y Y TPF, Cisplatin None No/No

2 48 F§ Nasopharynx T1N3M0

70 Gy Y Y

Cisplatin, 5‐fluorouracil

None No/No

3 80 M Hypopharynx, Epiglottis

T4N1M0, T1N1M0

70 Gy N Y Erbitux None Yes/No

4 53 M Left base of tongue

T2N2bM0 70 GY Y Y Taxotere, Erbitux

None No/No

5 66 M Left tonsil T2N2bM0 66 Gy N Y Cisplatin Tonsillectomy Yes/Yes

6 59 M Nasopharynx T4N2M0

70 Gy Y Y

TPF, Cisplatin & Gemcitabine

None No/No

7 55 M Right tonsil T1N2bM0 70Gy N Y Cisplatin Tonsillectomy Yes/No

8 47 M Right oral tongue

T1N0M0

70 Gy N Y Unavailable¶ Partial

glossectomy No/No

9 48 M Left Base of tongue

T0N2bM0 70 Gy Y Y TPF, Cisplatin Neck

dissection No/No

10 54 M Base of tongue

T4aN2cM0 70 Gy N Y Cisplatin None No/Yes


T1N2bM0 70 Gy N Y Cisplatin None Yes/Yes

12 45 M Right tonsil T2N2bM0 66 Gy Y Y Cisplatin Neck

dissection & tonsillectomy

No/No

13 76 M Right vocal

fold T4N0M0 70 Gy N Y Cisplatin None Yes/No

14 56 M Unknown primary

T0N1M0

70 Gy N Y Erbitux Tonsillectomy Yes/No

15 61 F Right tonsil T2N2bMX 70 Gy N Y Cisplatin Tumor

debulking Yes/Yes

16 50 M Right tonsil T2N2bM0 70 Gy Y Y Carboplatin None Yes/Yes

17 67 M Base of tongue

T1N2cM0

70 Gy N Y Carboplatin None No/Yes

18 65 F Right base of

tongue T2N2bM0 70 Gy N Y Cisplatin None Yes/Yes


T2N2bM0 72 Gy N Y Cisplatin None No/Yes

20 55 F Right base of

tongue T1N2cM0

70 Gy N Y Cisplatin

Right neck dissection

Yes/No

21 42 M Left palatine

tonsil T2N2bM0 70 Gy N Y Cisplatin None No/No

21

Table 2: Distribution of Tumor Sites among PatientsTumor Location Number of Patients Oral tongue 1 Nasopharynx 3 Base of tongue 8 Tonsil 5 Hypopharynx 1 Larynx (vocal folds) 1 Unknown primary 1

Table 3: Pre and Post‐Treatment Incidence of Penetration and Aspiration by Bolus Type

Bolus Type Pre‐treatment: Penetration Occurrences

Post‐treatment: Penetration Occurrences

Pre‐treatment: Aspiration Occurrences

Post‐treatment: Aspiration Occurrences

1mL thin liquid 0 3 0 1 10mL thin liquid 2 6 0 2 3mL nectar‐thick liquid 1 6 0 3*

10mL nectar‐thick liquid 0 5 0 1 3mL thin puree 0 1 0 0 3mL standard puree 0 3 0 2 Cookie 0 1 0 0 *The one instance in which a patient coughed in response to aspiration was on this bolus type (8/9 occurrences were “silent”).

Table 4: Correlations between Perception Ratings and Measures of Swallow Physiology by Bolus Type Perception ratings by

bolus type Oral transit

time Pharyngeal

response time Pharyngeal delay time

Pharyngeal transit time

Oral residue

Pharyngeal residue

1mL thin liquid 0.258 0.065 ‐0.076 ‐0.061 0.029 0.108 10mL thin liquid 0.152 ‐0.225 0.105 ‐0.133 0.012 0.144

3mL nectar‐thick liquid ‐0.044 ‐0.044 ‐0.102 0.126 ‐0.046 0.066 10mL nectar‐thick liquid ‐0.093 ‐0.188 0.102 ‐0.05 0.098 0.159

3mL thin puree ‐0.125 ‐0.323 0.063 ‐0.091 ‐0.204 ‐0.088 3mL standard puree ‐0.028 0.053 0.059 0.064 ‐0.128 0.508*

Cookie 0.357 ‐0.224 ‐0.113 ‐0.220 ‐0.167 0.415 *Asterisk denotes a statistically significant Pearson’s correlation coefficient.

21

Figures:

Figure 1: Changes in mean oral residue percentages per bolus type

Figure 2: Changes in mean pharyngeal residue percentages per bolus type

0

2

4

6

8

10

12

1mL thin

liquid

10mL

thin

liquid

3mL

nectar

liquid

10mL

nectar

liquid

3mL thin

pudding

3mL

pudding

cookie

Pe

rce

nt

resi

du

e

Oral Residue

Pre-

treatment

Post-

treatment

0

2

4

6

8

10

12

14

16

18

20

22

24

1mL thin

liquid

10mL

thin

liquid

3mL

nectar

liquid

10mL

nectar

liquid

3mL thin

pudding

3mL

pudding

cookie

Pe

rce

nt

resi

du

e

Pharyngeal residue

Pre-tx

Post-tx

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Head & Neck

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Figure 3: Mean perception per bolus ratings by bolus type

Figure Legends:

Figure 1: This figure illustrates the mean percentages of oral residue with standard error bars for each

bolus type at pre- and post-treatment assessment points.

Figure 2: This figure illustrates the mean percentages of pharyngeal residue with standard errors bars

for each bolus type at pre- and post-treatment assessment points.

Figure 3: This figure shows the mean patient ratings for swallowing difficulty with standard errors bars

for each bolus type at pre- and post-treatment.

0.5

1

1.5

2

2.5

3

1mL thin

liquid

10mL thin

liquid

3mL

nectar

thick

10mL

nectar

thick

3mL thin

pudding

3mL

pudding

Cookie

Pe

rce

pti

on

Ra

tin

gs

Patient Perception Ratings

Pre-

treatment

Post-

treatment

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