Dysphagia Management in Head and Neck Cancers

Krishnakumar Thankappan Subramania Iyer • Jayakumar R. MenonEditors

Dysphagia Management in Head and Neck Cancers

A Manual and Atlas

ISBN 978-981-10-8281-8 ISBN 978-981-10-8282-5 (eBook)https://doi.org/10.1007/978-981-10-8282-5

Library of Congress Control Number: 2018949613

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EditorsKrishnakumar ThankappanDepartment of Head and Neck Surgery and OncologyAmrita Institute of Medical SciencesAmrita Vishwa VidyapeethamKochiIndia

Jayakumar R. MenonDepartment of LaryngologyKerala Institute of Medical Sciences Thiruvananthapuram and Dysphagia UnitAmrita Institute of Medical SciencesAmrita Vishwa VidyapeethamKochiIndia

Subramania IyerDepartment of Head and Neck Surgery and OncologyAmrita Institute of Medical SciencesAmrita Vishwa VidyapeethamKochiIndia

To my loving parents Thankappan and Omana.and Amrutha, Hemanth, and Sruthi for their unwavering affection and support.

Krishnakumar Thankappan

To all my patients and trainees who keep on inspiring me.Subramania Iyer

To my great teachers Professor S. Krishnamoorthy and the late Professor N. Balakrishna Pillai.

Jayakumar R. Menon

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Dysphagia is an underrecognized sequela affecting both survival and quality of life of more than half of the patients during their treatment for head and neck cancers. Long-term results of the pivotal RTOG 91-11 trial that caused a paradigm shift towards the nonsurgical management of head and neck can-cers suggested aspiration and chronic dysphagia as the probable cause of increased late deaths impacting survival. Similarly, Machtay analyzing three chemoradiotherapy RTOG trials (91-11, 97-03, 99-14) for locally advanced head and neck cancers found that over 40% of patients have late toxicity, primarily related to speech and swallowing. Dysphagia is also a serious con-cern following ablative surgery due to alteration in the anatomical structures associated with swallowing. With oncologists focusing efforts at improve-ment of survival, important factors such as dysphagia have been traditionally overlooked and underreported. As a result, there has also been a paucity of publications addressing this important issue. Dr. Iyer, Dr. Thankappan, and Dr. Menon need to be congratulated for their efforts in bringing out this monograph Dysphagia Management in Head and Neck Cancers. The book has been astutely crafted into five sections, 33 chapters, providing a compre-hensive coverage on the topic. In addition, the atlas including videos demon-strating swallowing evaluation and management closely simulates a real-life situation making it easier for the reader to assimilate. There is something in the book for all those who treat head and neck cancers, namely the surgeon, the radiation oncologist, and the speech and swallowing specialist. It makes easy reading for beginners in the field as well as delves into the finer nuances of the subject for the more seasoned clinician. This book fills a much-needed void in the head and neck literature and is a must read for all in the field.

Anil K. D’CruzTata Memorial Hospital

Mumbai, India

Foreword

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The functional morbidity associated with the disease and its treatment has been a stigma associated with head and neck cancers from time immemorial to the present day. In the earlier ages, the versions of less sophisticated radia-tion therapy, large defects caused by the surgery, and the inappropriate man-agement protocols led to ghastly appearances and crippling functional disability to the patients who survived the disease. The survival rate has improved, and more patients with advanced stage disease can be cured now. The advances in minimally invasive surgery, application of lasers and other surgical tools, widespread use of microvascular reconstructive methods, and development of precision radiotherapy have helped to decrease the morbidity associated with the treatment of these cancers. But, with the quest for improv-ing disease control, newer modalities of treatment and management protocols are implemented. The morbidity associated with such regimens involving advanced surgical resection and use of primary and adjunct chemoradiation has thrown at us the challenges related to short-term and long-term morbidity. Added to this is the increasing number of geriatric patients who get cured, but have lesser ability to withstand the morbidity. Among the morbidity associ-ated with the head and neck cancers and its treatment, dysphagia is the most distressing one.

Dysphagia associated with head and neck cancers has been a poorly dis-cussed topic till last decade. Not much attention was given to studying its prevalence, fixing the etiological factors or implementing preventive and therapeutic measures. But recent studies have shown that dysphagia if under-stood and tackled well can improve the quality of life of these patients. Head and neck cancers have numerous subsite differences in their behavior and treatment. Dysphagia associated with cancers of the oral cavity and those of the laryngopharynx is entirely different. Similarly, the dysphagia associated with radiation and chemoradiation is different and needs a specialized approach to tackle them. The management of dysphagia is to be started along with the start of the treatment with many patients needing care for several years after cure of the disease. This is carried out by a multidisciplinary team. Dysphagia management needs to be appreciated and practiced by all mem-bers of the team. In fact, a dedicated dysphagia management specialist has to be an integral part of the head and neck cancer management team.

This book has been written with the purpose to impart insight into dyspha-gia associated with head and neck cancers. The initial chapters deal with the physiology of swallowing and pathophysiology of the dysphagia-related

Preface

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structures. The assessment of dysphagia is discussed in detail with the empha-sis being given to the clinical and instrumental evaluations. Features of dys-phagia related to common subsite cancers are discussed individually. Considering the fact that dysphagia associated with chemoradiotherapy is being seen in an alarmingly increased manner, preventive measures both in radiation therapy techniques and the institution of preventive swallowing therapy measures have been given due importance. Direct and indirect swal-lowing therapy methods involving postures and exercises are still an enigma to the clinician. This has been dealt with in a detailed and simple manner to enable them to be practiced routinely. Issues like nutritional management, ways of alternate feeding, and special problems associated with tracheostomy have a great bearing on the day-to-day management of the patients with dys-phagia. All these issues are dealt with in separate chapters. Finally, the cur-rent status of research and prospects is also included. The book is also designed as an atlas including videos. Wherever appropriate, videos are included for a better explanation of the subject.

This book is intended to be useful to all clinicians involved in head and neck cancer management. Each chapter discusses the concerned issue in detail, but for ease of practice, salient aspects are highlighted as pearls of wisdom in each chapter. The book is also designed to be useful to the swal-lowing therapists who intend to take the management of dysphagia associated with head and neck cancers as part of their practice. Hopefully, this should encourage more people to take up dysphagia management more passionately and improve the quality of life of the head and neck cancer patients we treat befitting to the current philosophy “Quantity of the cure is important, but equally important is the quality of the cure.”

Kochi, India Krishnakumar Thankappan Subramania Iyer

Jayakumar R. Menon

Preface

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We would like to express our sincere gratitude to the Medical Director, Principal, and the management of Amrita Institute of Medical Sciences, Kochi, Kerala, India, for their support to make this book a reality. The fel-lows, trainees, and staff of the Department of Head and Neck Surgery and Oncology and the Division of Swallowing therapy have also helped immensely. A special word of appreciation also goes to Drs. Deepak Balasubramanian and Vidhyadharan Sivakumar for their help in the scientific content. Bri. Abhirami, Mr. Dinesh, and other staff from the Department of Graphics and Mr. Kishorkumar, Mr. Ajithkumar, and Mr. Rajiv from the Department of Audio-Video Services of the institute also deserve special mention for their help in the preparation of illustrations and videos. Mr. Sanoj Viswam and Mr. Vivek volunteered as the models in the videos and that added to the perfection of the book.

Krishnakumar ThankappanSubramania IyerJayakumar R. Menon

Acknowledgments

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Part I Anatomy and Physiology

1 Anatomy of Swallowing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Priyank V. Rathod, Sivakumar Vidhyadharan, and Subramania Iyer

2 Physiology of Swallowing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Khyati Kamleshkumar Jani, Sivakumar Vidhyadharan, and Subramania Iyer

Part II Evaluation

3 Pretreatment Counseling Education and Training . . . . . . . . . . . . 45Sivakumar Vidhyadharan

4 Clinical Swallow Evaluation in Head and Neck Cancer . . . . . . . . 55Brenda Capobres Villegas

5 Videofluoroscopy Swallow Study: Technique and Protocol . . . 67Laishyang (Melody) Ouyoung

6 Flexible Endoscopic Evaluation of Swallowing (FEES): Technique and Interpretation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73Unnikrishnan K. Menon

7 Transnasal Esophagoscopy and Esophageal Manometry . . . . . . . 83Jayakumar R. Menon and Ragitha Binu Krishnan

8 Scintigraphic Evaluation of Swallowing . . . . . . . . . . . . . . . . . . . . . 89P. Shanmuga Sundaram and Padma Subramanyam

Part III Management Principles

9 Principles in the Management of Head and Neck Cancer . . . . . 103Shreya Bhattacharya

10 General Principles in the  Management of Dysphagia . . . . . . . . 111Krishnakumar Thankappan, Anju Elsa Varghese, and Mydhili Mayadevi

Contents

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11 Rehabilitative Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115Mydhili Mayadevi and Krishnakumar Thankappan

12 Compensatory Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129Anju Elsa Varghese and Krishnakumar Thankappan

13 Neuromuscular Electrical Stimulation (NMES) . . . . . . . . . . . . . 141Krishnakumar Thankappan and Subramania Iyer

14 Phagosurgery: Surgical Management of Dysphagia . . . . . . . . . . 147Jayakumar R. Menon, Manju E. Issac, Subramania Iyer, and Krishnakumar Thankappan

15 Trismus in Head and Neck Cancer: Causes and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161Adharsh Anand, Anil Mathew, and Deepak Balasubramanian

16 Diet and Nutritional Considerations . . . . . . . . . . . . . . . . . . . . . . . 173Adharsh Anand and Deepak Balasubramanian

17 Tube Feeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183Jayanthy Pavithran

18 Psychosocial and Quality of Life Issues in Dysphagia . . . . . . . . . 199Sunitha Daniel

19 Aspiration and Related Complications . . . . . . . . . . . . . . . . . . . . . 211Deepak Balasubramanian

Part IV Dysphagia Following Surgery

20 Dysphagia After Lip and Oral Cavity Surgery . . . . . . . . . . . . . . 221Samskruthy P. Murthy, Krishnakumar Thankappan, and Jayakumar R. Menon

21 Dysphagia After Oropharyngeal Surgery . . . . . . . . . . . . . . . . . . . 241Samskruthi P. Murthy, Krishnakumar Thankappan, and Subramania Iyer

22 Dysphagia After Laryngeal Surgery . . . . . . . . . . . . . . . . . . . . . . . 257Narayana Subramaniam, Anju V. Nikitha, and Krishnakumar Thankappan

23 Dysphagia After Hypopharyngeal Surgery . . . . . . . . . . . . . . . . . 277Narayana Subramaniam, Arya C. Jaya, and Jayakumar R. Menon

24 Cranial Nerve Palsy and Dysphagia . . . . . . . . . . . . . . . . . . . . . . . 287Shashikant Vishnubhai Limbachiya, Krishnakumar Thankappan, and Jayakumar R. Menon

25 Tracheostomy and Intubation- Related Dysphagia . . . . . . . . . . . 297Deepak Balasubramanian

Contents

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Part V Dysphagia Following Radiotherapy/Chemoradiotherapy

26 Swallowing Dysfunction After Radiotherapy and Chemotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305Prameela Chelakkot

27 Preventive Strategies in Radiation- Associated Dysphagia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321Debnarayan Dutta and Krishnakumar Thankappan

28 Management of Dysphagia Following Radiotherapy . . . . . . . . . 333Shashikant Vishnubhai Limbachiya, R. Anoop, and Krishnakumar Thankappan

29 Mucositis: Prevention and Management . . . . . . . . . . . . . . . . . . . 349R. Anoop

30 Pain Management During Radiotherapy for Head and Neck Cancers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357Charu Singh

Part VI Summary

31 Components of Swallow, Impairments, Causes, Observations, and Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371Krishnakumar Thankappan and Jayakumar R. Menon

32 Translational Research for Rehabilitation of Swallowing in Head and Neck Cancer Patients . . . . . . . . . . . . . . . . . . . . . . . . 383Uttam K. Sinha

33 Setting Up a Swallowing Clinic . . . . . . . . . . . . . . . . . . . . . . . . . . . 399Jayakumar R. Menon and Arya R. Raj

Contents

xvii

Adharsh  Anand Department of Head and Neck Surgery and Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

R. Anoop Department of Radiation Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

Deepak  Balasubramanian Department of Head and Neck Surgery and Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

Shreya  Bhattacharya Department of Surgical Oncology, Max Super Speciality Hospital, Saket, New Delhi, India

Prameela Chelakkot Department of Radiation Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

Sunitha  Daniel Department of Palliative Medicine, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

Debnarayan Dutta Department of Radiation Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

Manju  E.  Issac Department of Laryngology, Kerala Institute of Medical Sciences, Thiruvananthapuram, Kerala, India

Subramania  Iyer Department of Head and Neck Surgery and Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

Khyati Kamleshkumar Jani Department of Head and Neck Surgery and Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

Arya C. Jaya Department of Head and Neck Surgery and Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

Ragitha  Binu  Krishnan Department of Laryngology, Kerala Institute of Medical Sciences, Thiruvananthapuram, Kerala, India

List of Contributors

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Shashikant  Vishnubhai  Limbachiya Department of Head and Neck Surgery and Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

Anil  Mathew Department of Prosthodontics, Amrita School of Dentistry, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

Mydhili Mayadevi Department of Head and Neck Surgery and Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

Jayakumar  R.  Menon Department of Laryngology, Kerala Institute of Medical Sciences, Thiruvananthapuram, Kerala, India

Dysphagia Unit, Department of Head and Neck Surgery, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

Unnikrishnan K. Menon Department of ENT, Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

Samskruthi  P.  Murthy Department of Head and Neck Surgery and Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

Anju  V.  Nikitha Department of Head and Neck Surgery and Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

Laishyang  (Melody)  Ouyoung Keck Medical Center, USC Caruso Department of Otolaryngology-Head and Neck Surgery, University of Southern California, Los Angeles, CA, USA

Jayanthy  Pavithran Department of ENT, Amrita Institute of medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

Arya  R.  Raj Department of Laryngology, Kerala Institute of Medical Sciences, Thiruvananthapuram, Kerala, India

Priyank V. Rathod Department of Head and Neck Surgery and Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

P.  Shanmuga  Sundaram Department of Nuclear Medicine & Molecular Imaging, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

Charu Singh Department of Palliative Medicine, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

Uttam  K.  Sinha Department of Head and Neck Surgery, Keck Medical Center, University of Southern California, Los Angeles, CA, USA

Narayana  Subramaniam Department of Head and Neck Surgery and Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

List of Contributors

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Padma  Subramanyam Department of Nuclear Medicine & Molecular Imaging, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

Krishnakumar  Thankappan Department of Head and Neck Surgery and Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

Anju Elsa Varghese Department of Head and Neck Surgery and Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

Sivakumar  Vidhyadharan Department of Head and Neck Surgery and Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

Brenda  Capobres  Villegas Keck Medical Center, University of Southern California, Los Angeles, CA, USA

USC Voice Center, USC Caruso Department of Otolaryngology-Head and Neck Surgery, Los Angeles, CA, USA

List of Contributors

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About the Editors

Krishnakumar  Thankappan is a professor in the Department of Head and Neck Surgery and Oncology at Amrita Institute of Medical Sciences, Kochi, India. He completed his basic training in Otolaryngology at BJ Medical College, Pune; his MCh in Head and Neck Surgical Oncology at Amrita Institute of Medical Sciences, Kochi; and his advanced fellowship in Head and Neck Oncology at Roswell Park Cancer Institute, Buffalo, USA.  He is the recipient of the Young Investigator Award from the Indian Co-operative Oncology network and has published more than

60 papers in international journals. He serves as a reviewer for several inter-national journals and is the Regional Editor (Asia Pacific) for the Journal of Cranio-Maxillary Trauma and Reconstruction. He has written a book titled Basic Concepts in Head and Neck Surgery and Oncology.

Subramania  Iyer graduated from the Medical College, Kottayam, in 1979, before completing his higher surgical training in Head and Neck Surgery and Plastic Surgery from AIIMS, New Delhi; Medical College, Calicut; and various cen-ters in the United Kingdom. He did a fellowship in Craniofacial Surgery at Mexico City, UICC; in Laryngeal Cancer Surgery at Center Oscar Lambret, Lille; and in Tissue Engineering at Rice University, Houston. Currently, he is a professor and head of the Division of Reconstructive

Surgery and Head and Neck Surgery/Oncology at the Amrita Institute of Medical Sciences, Kochi. Dr. Iyer is the past president of the Foundation for Head and Neck Oncology of India, secretary of the Indian Society of Microsurgery, president of the Head and Neck Co-Operative research group, member of the executive council of the Association of Plastic Surgeons of India, and president of the Eurasian Association of Head and Neck Oncology. He has written several international publications and serves as a reviewer for many journals in the field of otolaryngology and plastic surgery.

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Jayakumar R. Menon is a consultant laryngol-ogist at Kerala Institute of Medical Sciences, Thiruvananthapuram and Dysphagia Clinic, Amrita Institute of Medical Sciences, Kochi. He trained in laryngology under John D Russell in Dublin, Ireland. He is the founder vice president and past president of the Association of Phonosurgeons of India. He has given lectures, orations, and keynote addresses in laryngology at numerous state, national, and international con-ferences. He has been an invited speaker at numerous international conferences including the

last two World Voice Congresses and the World ENT Congress 2013 and 2017. He has contributed chapters in four international textbooks and pub-lished several papers in national and international journals. He has also described a clinical sign to diagnose abductor spasmodic dysphonia.

About the Editors