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Does Laryngectomy Improve Swallowing After Chemoradiotherapy?
A Case Study
Cathy Lazarus, PhD;
Jeri A. Logemann, PhD;
Guoxiang Shi, MD, PhD;
Peter Kahrilas, MD;
Harold Pelzer, MD;
Kara Kleinjan, MA
Arch Otolaryngol Head Neck Surg. 2002;128:54-57.
ABSTRACT
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Organ preservation protocols of high-dose chemoradiotherapy have become
fairly common to treat head and neck cancers. However, significant swallowing
problems can occur. This study examines swallowing, oral tongue pressures,
and tongue base–to–pharyngeal wall pressures in a patient who
underwent total laryngectomy for improvement of swallowing after chemoradiotherapy
for treatment of a hypopharyngeal tumor. The patient underwent concurrent
videofluorographic and manometric examination of swallowing and examination
of oral tongue pressures after the laryngectomy. One healthy subject was used
as a control. After the laryngectomy, the patient no longer aspirated; however,
he could swallow only liquids and pureed foods. He demonstrated difficulty
with bolus clearance through the oral cavity and pharyngocervical esophagus.
Pharyngeal pressures were reduced compared with those of the control subject.
While total laryngectomy will stop unremitting aspiration, swallowing after
chemoradiation may be severely compromised. This may not be overcome by total
laryngectomy.
INTRODUCTION
Organ preservation protocols consisting of high-dose chemoradiotherapy
have become fairly common for treatment of head and neck cancers.1-2 However, significant swallowing problems
often occur after this treatment.3-4
Total laryngectomy has been an option for patients having undergone head and
neck cancer treatment and who exhibit unremitting posttreatment aspiration.5 However, no study has examined swallowing after total
laryngectomy for chronic aspiration in patients having undergone high-dose
chemoradiotherapy. This study examines (1) swallowing, (2) oral tongue pressures,
and (3) tongue base–to–pharyngeal wall pressures in a patient
who underwent total laryngectomy for improvement of swallowing after primary
chemoradiotherapy for treatment of a hypopharyngeal tumor. The same study
was completed in an age- and sex-matched control subject.
PATIENT AND METHODS
A 72-year-old man was treated for a newly diagnosed stage IV squamous
cell cancer of the hypopharynx. He underwent organ preservation treatment
of concurrent external beam radiotherapy and chemotherapy, receiving a total
radiotherapeutic dose of 7000 rad and chemotherapy consisting of cis-platinum,
fluorouracil, and hydroxyurea. A videofluorographic (VFG) swallow study completed
mid-treatment revealed poor tongue-base motion, reduced laryngeal elevation,
and closure during swallowing, all of which resulted in poor bolus clearance
and aspiration after the swallow. A gastrostomy tube was subsequently placed
because of impaired swallow function and poor oral intake. This patient also
required a tracheostomy tube for airway maintenance and management of secretions.
The patient underwent swallow therapy to improve tongue-base posterior motion,
laryngeal elevation, and closure for swallowing. A second VFG swallow evaluation
1 month following completion of his chemoradiotherapy revealed no improvement
in swallow function. He continued to receive all nutrition through a gastrostomy
tube and continued swallow therapy.
Over the year after his chemoradiotherapy, the patient's swallowing
did not improve. Because of his strong desire to eat normally, and his unremitting
aspiration despite therapy procedures, he subsequently underwent total laryngectomy
without hyoid bone resection. After surgery, he was still unable to swallow
and was reevaluated using concurrent VFG and manometric (manofluorographic)
examination,6 as well as a study of oral tongue
pressures. One age- and sex-matched healthy subject, a 67-year-old man, served
as a control. He underwent an in-depth interview that revealed no history
of swallowing problems or diagnoses that might affect swallow function. The
control subject underwent one manofluorographic study and one evaluation of
oral tongue pressures.
Oropharyngeal swallowing was assessed using VFG, the modified barium
swallow procedure.7 Subjects were given 2 swallows
each of 1, 3, 5, and 10 mL of liquid and 3 mL of paste boluses. Subjects were
then instructed in the effortful swallow, designed to improve tongue-base
posterior motion,8 with each subject performing
2 swallows in this manner on 3-mL pastes. The radiographic image was recorded
on a Sony Umatic VO-9600 videotape recorder (Bensenville, Ill) coupled to
a Thalner Electronics (Ann Arbor, Mich) counter-timer (TEL VC436) for subsequent
slow-motion and frame-by-frame analysis. Observations and swallow measures
were made for each swallow, including (1) observation of the approximate percentage
of residue in the oral cavity and pharyngocervical esophagus after the swallow;
(2) temporal measures of bolus movement through the oral cavity and pharyngocervical
esophagus; and (3) measures of structural movement over time for each swallow.
Temporal measures of bolus movement through the oral cavity and pharyngocervical
esophagus included (1) oral transit time (time from the onset of the posterior
movement of the bolus head until the bolus head reached the point where the
tongue base crossed the ramus of the mandible); (2) pharyngocervical esophageal
transit time (time from the onset of the bolus head reaching the point where
the tongue base crosses the ramus of the mandible until the bolus tail passes
through the esophagus at the horizontal level of superior C5); and (3) duration
of bolus transit through the cervical esophagus at the horizontal level of
superior C5 (time from when the bolus head reached the esophagus at the horizontal
level of superior C5 until the bolus tail passed this point) (Figure 1). This last measure was used instead of cricopharyngeal
opening duration, since the cricopharyngeal region cannot be reliably identified
after total laryngectomy.
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A, Radiographic lateral view of the patient with the manometric catheter
in place; note the lower sensor behind the tongue base. B, Schematic lateral
view with marked points identifying the mid-C2 (MC2), inferior C2 (IC2), superior
C3 (SC3), and superior C5 (SC5) vertebrae. PPW indicates posterior pharyngeal
wall.
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Measures of pharyngeal structural movement during the swallow included
(1) tongue-base movement to the posterior pharyngeal wall (PPW) (from the
onset of posterior movement of the tongue base until it first contacts the
PPW); (2) duration from first to last contact of the tongue base to PPW at
mid-C2; (3) duration from first to last contact of the tongue base to PPW
at inferior C2; (4) duration from first to last contact of tongue base to
PPW at superior C3; (5) duration of velopharyngeal closure (from first to
last contact of the palate to the PPW); and (6) duration of hyoid movement
(from first to last movement of the hyoid). Interobserver and intraobserver
reliability measures were performed on 2 swallows per subject. Pearson correlation
coefficients of intraobserver and interobserver reliability for all swallow
observations and measures averaged 0.99 (range, 0.98-1.00) and 0.99 (range,
0.94-1.00), respectively.
Manometry was used concurrently with VFG to examine tongue base–to–PPW
pressures.6 Manometry was accomplished using
an intraluminal transducer system with a 2-channel solid-state catheter, the
transducers of which were 3 cm apart. The manometric catheter was inserted
transnasally with the transducers oriented posteriorly. The catheter was passed
through the pharyngocervical esophageal region, and was then withdrawn until
the proximal transducer was situated behind the tongue base. Catheter pressures
(millimeters of mercury) were recorded for each swallow. Subjects were seated
upright and viewed in the lateral VFG plane.
Oral tongue pressures were assessed in a separate session on the same
day as the VFG swallow evaluation using the Iowa Oral Performance Instrument.9 Subjects performed 3 tongue-pressure tasks during
which maximum pressures were measured and 1 task during which duration was
measured, including (1) maximum isometric pressure (Pmax = strength);
(2) normal dry swallows; (3) effortful swallows; and (4) sustained submaximal
pressure generation (50% Pmax = endurance [duration]). Subjects
performed 3 trials of each.
Data on the swallow observations of percentage residue and temporal
and pressure measures of swallowing were averaged across trials for each bolus
volume, viscosity, and condition. For maximum tongue pressure testing, the
greatest value for the 3 trials was used as Pmax. The greatest
value for the 3 trials of tongue endurance was used as the tongue endurance
measure for each subject. Tongue strength values during normal and effortful
swallowing were averaged for each task.
RESULTS
Total laryngectomy successfully eliminated aspiration. However, the
patient reported that he was initially able to swallow only liquids by mouth.
After several weeks he could swallow only some pureed foods, as determined
by VFG results and patient report. Results revealed that after total laryngectomy
the patient had difficulty with bolus clearance through the oral cavity and
pharyngocervical esophagus during swallows (Table 1). The percentage of oral residue was higher for liquids
and pastes in the patient than it was in the control subject. Percentages
of pharyngocervical esophageal residue also increased with thicker boluses
(pastes); most of the bolus remained in the pharyngocervical esophagus after
the patient swallowed. Bolus clearance through the pharyngocervical esophageal
region was also slowed, with prolonged pharyngocervical esophageal transit
times, particularly on paste swallows, compared with measures in the control
subject. Tongue-base contact to the pharyngeal wall was incomplete for some
swallows at the inferior C2 level and was incomplete for all swallows at the
superior C3 level.
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Table 1. Swallow Observations and Measures of Bolus and Structural
Movement During the Swallow for 1, 3, 5, and 10 mL of Liquid and 3-mL Paste
Boluses and the Effortful Swallow in the Patient (P) and Control Subject (C)*
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Tongue base–to–pharyngeal wall pressures during the swallow
for the patient were lower than those in the control subject (Table 2) and lower than pressures typically generated after total
laryngectomy (mean pressure, 86 mm Hg).6 Pharyngeal
pressures across all volumes on liquid swallows were similar to those in patients
with total laryngectomy and tongue impairment (mean pressure, 31 mm Hg).10 Although the patient's tongue base–to–pharyngeal
wall pressures increased with use of the effortful swallow, they did not approach
those reported in patients with total laryngectomies without tongue impairment,6 and bolus clearance through the pharynx did not improve
over the normal swallows.
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Table 2. Tongue Base–to–Pharyngeal Wall Pressures During
Swallows of 1, 3, 5, and 10 mL of Liquid, 3-mL Paste Boluses, and the Effortful
Swallow for the Patient Control and Control Subject*
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Mean values for maximum isometric tongue pressures (Table 3) were higher for the patient than for the control subject,
although still within normal limits for healthy older adults.11
Tongue endurance measures were shorter for the patient than for the control
subject, both measures being below those of normal older adults.12
Oral tongue pressures during dry swallowing were not appreciably different
for the patient and the control subject, and both showed values that were
below normal for older adults.11 Tongue pressures
increased during effortful swallows for both subjects.
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Table 3. Oral Tongue Pressure Measures of Maximum Strength and Endurance
Tasks, and During Normal and Effortful Swallow in the Patient and Control
Subject*
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COMMENT
Total laryngectomy eliminated the risk of aspiration in this patient.
However, for this patient with compromised swallow functioning after chemoradiotherapy,
total laryngectomy did not significantly improve his diet. Pressure is generated
during swallows by the tongue, tongue base, and pharyngeal walls.6, 10, 13 Studies of total laryngectomy
show that individuals must typically generate pressures greater than normal
during the swallow to achieve bolus transit.6
This patient's chemoradiation resulted in poor tongue-base motion prior to
his total laryngectomy, and he was unable to produce the higher-than-normal
pressures needed to clear thicker boluses through his reconstructed pharyngocervical
esophagus after his laryngectomy.
The fact that this patient demonstrated higher maximum oral tongue pressures
than the control subject may represent his attempt to generate the higher
pressures needed to swallow efficiently. The patient was edentulous at the
time of his tongue function assessment and the control subject had some teeth.
Greater tongue strength has been observed in the healthy edentulous population
than in similar subjects with teeth or dentures.14
Radiotherapy to the head and neck often results in fibrosis and scarring
of the pharyngeal tissues and structures. These changes can contribute to
a reduction in the range of motion of the tongue base and pharyngeal musculature
and structures.4 Patients of this sort might
benefit from tongue-base range-of-motion exercises, including the tongue-hold
maneuver, tongue-base retraction, and the effortful swallow because pharyngeal
pressures during swallowing are known to improve with use of these maneuvers.15 In addition, tongue-strengthening exercises might
improve tongue-base strength for swallowing in this patient, since the tongue
creates the major bolus-driving pressure.13
However, with impaired range and flexibility of the pharyngeal musculature,
it is unclear to what degree this patient would benefit from this therapy.
This case study highlights the importance of careful laryngectomy swallow
preassessment in the patient with unremitting aspiration after chemoradiation
treatment. Examination of the patient's ability to generate pressures adequate
to swallow a normal diet before the laryngectomy will contribute significantly
to prelaryngectomy patient counseling.
AUTHOR INFORMATION
Accepted for publication August 29, 2001.
This research was supported by grant PO1CA40007 from the National Institutes
of Health/National Cancer Institute, Bethesda, Md.
Corresponding author and reprints: Cathy L. Lazarus, PhD, Northwestern
University Medical School, Voice, Speech and Language Service and Swallowing
Center, 201 E Huron St, Suite 10-205, Chicago, IL 60611 (e-mail: claz{at}northwestern.edu).
From the Voice, Speech and Language Service and Swallowing Center (Dr
Lazarus) and the Departments of Gastroenterology (Drs Shi and Kahrilas) and
Otolaryngology–Head and Neck Surgery (Dr Pelzer), Northwestern University
Medical School, Chicago, Ill; and the Department of Communication Sciences
and Disorders, Northwestern University, Evanston, Ill (Dr Logemann and Ms
Kleinjan).
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