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Prediction of Aspiration in Patients With Newly Diagnosed Untreated Advanced Head and Neck Cancer
Arie Rosen, MD;
Thomas H. Rhee, MD;
Rene Kaufman, MS, CCC-SLP
Arch Otolaryngol Head Neck Surg. 2001;127:975-979.
ABSTRACT
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Objectives To determine the prevalence of aspiration in patients with newly diagnosed
nontreated advanced head and neck cancer and to determine the ability of the
clinical examination to predict aspiration in this patient population.
Design A descriptive prevalence study of the presence of aspiration in patients
with advanced (stages III and IV) head and neck cancer and a prospective correlation
study between variables of the clinical evaluation with the criterion standard
videofluoroscopy.
Setting Regional veterans affairs medical center.
Patients A consecutive sample of 27 patients without previous treatment or tracheostomy.
Interventions All patients underwent evaluation by an otolaryngologist and speech
pathologist prior to videofluoroscopy.
Main Outcome Measures Variables in the dysphagia evaluation (consisting of a directed medical
history, physical examination, and food challenge), the self-rated 45-item
questionnaire, and the clinicians "educated prediction" of aspiration were
analyzed with reference to aspiration on videofluoroscopy using univariant
analysis.
Results The prevalence of aspiration determined by videofluoroscopy was 41%
(11 of 27 patients). Two (6%) of 32 items in the medical history, 1 (4%) of
25 items in the physical examination, and 8 (50%) of 16 items in the food
challenge were found to be statistically significantly correlated (P<.05) with aspiration on videofluoroscopy by univariate analysis.
Nine (25%) of 45 items in the self-rated questionnaire were correlated with
aspiration on videofluoroscopy. The clinicians' educated prediction of aspiration
was not correlated with aspiration determined by videofluoroscopy.
Conclusions Clinical evaluation alone is inadequate in predicting patients who aspirated,
determined objectively by videofluoroscopic swallowing study. Further study
is needed to develop an efficient dysphagia evaluation to identify patients
at risk for aspiration.
INTRODUCTION
MULTIPLE reports have focused on aspiration in the posttreatment phase
of advanced head and neck cancer (AHNC). Information is limited regarding
the incidence of aspiration in patients with newly diagnosed AHNC in the pretreatment
phase.1 To the best of our knowledge, no data
regarding the effectiveness of existing clinical tools for prediction of aspiration
in this population have been reported.
Patients with AHNC may demonstrate swallowing dysfunction for a variety
of reasons. Tumor mass may impair mobility of structures such as the larynx
or tongue, it may also disrupt the laryngeal protective sphincter mechanism.
Sensation in the upper aerodigestive tract may be altered when large mucosal
surface areas are replaced by tumor, or when neural invasion occurs. Sensation
and the fine coordinated motor function of swallowing may be further impaired
in patients with AHNC secondary to alcohol-induced sensory and/or motor neuropathy.2 These swallowing dysfunctions render the patient with
AHNC at a high risk for aspiration.
Once aspirating, the patients with AHNC are clearly at increased risk
for developing aspiration pneumonia because of poor nutritional status, smoking
history with associated pulmonary disease, cancer-related immune suppression,
and poor oral hygiene. However, the causal relationship between the presence
of aspiration and aspiration pneumonia has not been established for patients
with AHNC. This causal relationship has been established in one prospective
study examining the stroke population. The calculated relative risk for developing
pneumonia was 6.95 times greater for those who aspirated on videofluoroscopy
compared with those who did not.3 In retrospective
studies, the relationship between aspiration and aspiration pneumonia has
been similarly demonstrated.4-5
Prospective studies establishing the relationship between the presence of
aspiration on videofluoroscopy and aspiration pneumonia are scarce because
they require that the clinician face the ethical dilemma of continuing to
orally feed a patient who is known to aspirate. Although it is obvious that
the true cost of aspiration in the patient with AHNC is incalculable because
of the difficulty in obtaining prospective studies establishing this relationship,
it is reasonable to deduce that a similar relationship between aspiration
and aspiration pneumonia holds in patients with AHNC as well. Detection of
aspiration in the pretreatment phase of patients with AHNC is relevant only
if it has practical implications on the patient's management or outcome. If
surgery is anticipated, documenting aspiration may only help in the deliberation
prior to surgery; however, it is of limited comparative value, because surgery
may change the anatomy significantly making the pretreatment determination
obsolete. Pretreatment detection of aspiration becomes more relevant with
the increasing use of multimodality treatments and organ-preserving treatment
regimens. In patients receiving radiotherapy or chemotherapy, aspiration pneumonia
has the added potential morbidity associated with delay or interruption in
cancer treatment. It not only can delay surgical treatment, but also can adversely
affect continuity of radiotherapy or chemotherapy. Interruption of radiotherapy
has been shown to decrease cancer control rates. Each day of treatment interruption
in laryngeal cancer was calculated to result in an increased likelihood of
local relapse by 4.8%.6 Furthermore, treatment
gaps longer than 4 days were found to decrease local control of laryngeal
cancer and increase cancer-related mortality.7
In addition to determining patients at risk for aspiration pneumonia, if we
are to assess the functional outcome of organ preservation protocols, we must
assess baseline pretreatment function as well. Clearly, pretreatment evaluation
for aspiration is indicated in patients with AHNC.
Common standard tools in most institutions for assessment of aspiration
in patients with AHNC incorporate clinical examination, including a directed
medical history, physical examination, and food challenges, followed by videofluoroscopy.
This is a costly, time-consuming process requiring specially trained personnel.
The effectiveness of the commonly used clinical tools to predict aspiration
has not been reported specifically for patients with AHNC. To our knowledge,
there is no information evaluating what are effective clinical predictors
of aspiration in the nontreated AHNC population. This pilot study determined
the prevalence of aspiration in patients with newly diagnosed nontreated AHNC
and the ability of the clinical examination to predict aspiration in this
patient population.
PATIENTS AND METHODS
All newly diagnosed patients with stage III or IV squamous cell carcinoma
of the head and neck who presented to the Otolaryngology–Head and Neck
Service at the East Orange Veterans Affairs Medical Center, East Orange, NJ,
were evaluated for this study after review and approval of study protocol
by the institutional review board at the East Orange Veterans Affairs Medical
Center. Patients who had tracheostomy, surgery, or cancer treatment before
dysphagia evaluation were excluded from this study. Twenty-seven consecutive
patients between the ages of 49 and 87 years (mean age, 60 years) were included
in this study. The primary sites of the lesions were the larynx (10 patients),
oropharynx (9 patients), oral cavity (6 patients), and hypopharynx (2 patients).
For this study, all patients underwent a complete head and neck examination,
including a flexible laryngoscopic examination. This was followed by a dysphagia
evaluation by the speech and swallowing service administered by a speech pathologist.
A self-rated 45-item questionnaire was then administered. Finally, a videofluoroscopic
swallowing study was performed (Figure 1).
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Figure 1. Evaluation protocol.
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The evaluation for dysphagia was divided into 3 parts. (1) A directed
medical history consisting of 32 items addressing the patients' history of
difficulty swallowing, pneumonia, weight loss, pain, diet change, and voice
change. (2) Physical examination consisting of 25 items addressing labial,
mandibular, and tongue motion; perioral sensation; and voice pitch, phonation,
articulation, and quality. (3) A food challenge consisting of administering
liquids, puree, soft solids, and dry solids and observing for coughing and
choking or voice change.
A self-rated questionnaire consisting of 45 statistically balanced items
was developed for this study. Questions addressed 3 general areas related
to swallowing impairment: social changes, diet changes, and difficulty during
swallowing. Answers were graded on a 5-point severity scale. A standard Mini-Mental
Status Examination was administered to confirm adequate cognition.
Following the dysphagia evaluation and administration of the self-rated
questionnaire, but before videofluoroscopy, the speech pathologist made an
"educated prediction" as to whether the patient would aspirate. Videofluoroscopy
was then performed following standard protocol.8
Aspiration was noted if contrast media was seen below the vocal folds.
Each variable in the dysphagia evaluation, self-rated 45-item questionnaire,
and the educated prediction were analyzed independently. Univariate analysis
was used to determine the correlation of each item with the presence of aspiration
on videofluoroscopy. Because of the small sample size of this pilot study,
further statistical tests were not performed. Statistical significance was
set at P<.05.
RESULTS
PREVALENCE OF ASPIRATION
The prevalence of aspiration determined by videofluoroscopy was 41%
(11 of 27 patients). In 5 (45%) of 11 patients there was no effort to cough
or clear the airway when aspiration was seen on videofluoroscopy (silent aspiration).
Six (55%) of 11 had overt aspiration (Figure
2).
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Figure 2. Prevalence of aspiration.
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DYSPHAGIA EVALUATION
Two (6%) of 32 items in the directed medical history part, 1 (4%) of
25 items in the physical examination part, and 8 (50%) of 16 items in the
food challenge part were found to be significantly correlated (P<.05) with aspiration on videofluoroscopy by univariate analysis
(Table 1). For these items, the
correlation coefficient ranged from 0.36-0.47 (Table 2). The positive predictive value, negative predictive value,
sensitivity, specificity, and percentage correctly classified for each item
were calculated (Table 3). There
were 2 patients who appeared to have gross aspiration clinically and were
not tested with any food challenge owing to safety concerns. One patient who
grossly aspirated with liquids clinically was not tested with other consistencies.
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Table 1. Dysphagia Evaluation
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Table 2. Dysphagia Evaluation
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Table 3. Dysphagia Evaluation Correlation With Predictive Values, Sensitivity,
Specificity, and Correct Classification*
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SELF-RATED QUESTIONNAIRE
Nine (25%) of 45 items in our specifically designed study questionnaire
were found to be significantly correlated with aspiration on videofluoroscopy.
All questions related to difficulty or distress during swallowing. None of
the social or diet change questions were correlated with aspiration.
EDUCATED PREDICTION OF ASPIRATION
The clinicians' educated prediction of aspiration before videofluoroscopy
is given in Table 4. Overall,
18 (67%) of the 27 patients were correctly classified. The correlation of
prediction of aspiration with objective aspiration on videofluoroscopy by
univariate analysis was not statistically significant (P = .12).
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Table 4. Educated Prediction of Aspiration*
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COMMENT
The prevalence of aspiration determined by videofluoroscopy, in our
group of 27 patients is 41%. The number of patients in this pilot study is
small, not allowing for the comparison of the incidence of aspiration between
specific primary sites of tumor. To our knowledge, there is only 1 previously
reported documentation of the prevalence of aspiration in the newly diagnosed
nontreated AHNC population that similarly reported a 44% prevalence of aspiration
in a group of 78 patients.1 This along with
our report are the only 2 reports in which only consecutive untreated patients
were included. The 2 reports provide baseline reference data on the incidence
of aspiration in patients with untreated AHNC to which posttreatment data
may be compared. Muz et al9 did report an incidence
of aspiration of 33% in a large group of patients with head and neck cancer
determined by scintigraphy. However, this group was heterogeneous including
all patients regardless of treatment or presence of tracheostomy.
The percentage of silent aspiration in our group, defined as having
no detectable effort to clear the throat or cough during aspiration documented
on videofluoroscopy, was 45% (12 patients). Smith et al10
reported that of 51 patients with head and neck cancer who aspirated, 26 patients
(51%) did so silently. Patients were not differentiated regarding treatment
status or presence of tracheostomy. Our study and the University of Chicago
study1 clearly indicate that a high number
of patients in the head and neck cancer population are at risk for aspiration
even prior to tracheostomy or cancer treatment. Reports on aspiration in the
posttreatment phase should consider this high prevalence of aspiration in
the baseline pretreatment phase. Furthermore, many of these patients are silent
aspirators. Silent aspiration would go undetected without objective determination
by videofluoroscopy.
It would be desirable to be able to predict aspiration or to identify
the patient at risk for aspiration based on data obtained from a short-focused
clinical evaluation alone, without exposing all patients with AHNC to costly
videofluoroscopy. For this purpose, we first have to determine which elements
of the clinical evaluation are most useful in predicting aspiration. Standard
clinical dysphagia evaluation is administered by a skilled professional and
consists of a directed medical history, physical examination, and food challenge.
This subjective evaluation is used not only to detect aspiration but also
for therapeutic dietary modification. The clinical evaluation in our study
included 65 variables of which only 7 were correlated with aspiration on videofluoroscopy
(Table 2). Furthermore, the correlation
was not strong for these 7 variables in this pilot study (R = 0.36-0.47). The standard clinical evaluation used was inefficient
in the detection of aspiration as indicated by the small number of items that
correlated with the presence of aspiration. Further regression analysis to
see if any combination of variables can more accurately predict aspiration
awaits a larger patient sample size. In the stroke population, similar variables
(wet voice quality, coughing on liquids, and voice change with liquids) to
those found in our report were also found to correlate with the presence of
aspiration.11-17
However, to our knowledge, there are no similar reports available for comparison
with our data for patients with AHNC.
To be useful as a screening test, we, as clinicians, would prefer a
test with a high sensitivity. For these 7 correlating items, sensitivities
ranged from 0% to 45%. To rely solely on these items would fail to identify
55% to 100% of the aspirators. Thus, these variables are not useful as independent
screening tools for detection of aspiration. However, the specificity for
these variables was very high (88%-100%); with any of these variables present,
the clinician should have a high suspicion that the patient is aspirating.
Four of these 7 most predictive items involved a food challenge. The food
challenge is easy to administer as it requires very little time and no instrumentation
in the physician's office (or clinical setting). Much of the information obtained
from the remaining more time-consuming components of the dysphagia history
and physical examination cannot reliably predict aspiration.
The educated prediction of aspiration by a speech pathologist knowledgeable
in swallowing disorders was not found to be significantly correlated with
aspiration on videofluoroscopy. We, as clinicians, would fail if we relied
on intuition to identify which patients are aspirating.
In this pilot study, clinical evaluation alone does not seem to be reliable
or efficient for predicting aspiration in the AHNC population. More work is
needed to develop an efficient, focused, and directed dysphagia evaluation
that can more accurately alert the clinician to whether the patient aspirates
or to at least identify the patients who are at risk for aspiration. Until
more patients are evaluated to identify more accurate clinical predictors
of aspiration, we recommend videofluoroscopy for the objective determination
of aspiration in newly diagnosed nontreated AHNC. Pretreatment determination
of aspiration is indicated in many patients with AHNC, particularly those
who are candidates for organ-preservation protocols. Videofluorscopic evaluation
not only gives accurate information about aspiration, but also can be used
to direct the patient in diet changes, postural modifications, sensory enhancement
techniques, and various swallowing maneuvers to improve swallowing function.18-19 Developing a more efficient dysphagia
evaluation may free resources for rehabilitation endeavors.
CONCLUSIONS
The prevalence of aspiration in our pilot study in patients with newly
diagnosed untreated AHNC was 41%. Clinical evaluation alone is inadequate
in predicting patients who aspirated determined objectively by videofluoroscopy.
Though we have identified several elements in the clinical examination that
correlate with aspiration on videofluoroscopy, more study is needed to develop
an efficient dysphagia evaluation to identify patients most at risk.
AUTHOR INFORMATION
Accepted for publication February 7, 2001.
Corresponding author and reprints: Arie Rosen, MD, Division of Otolaryngology,
University of Medicine and Dentistry of New Jersey–New Jersey Medical
School, 90 Bergen St, Suite 7200, Newark, NJ 07103 (e-mail: ROSENAR{at}UMDNJ.EDU).
From the Division of Otolaryngology, University of Medicine and Dentistry
of New Jersey–New Jersey Medical School, Newark (Drs Rosen and Rhee);
and the Department of Audiology and Speech Pathology, East Orange Veterans
Affairs Medical Center, East Orange, NJ (Ms Kaufman).
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