Chapter 7 - Swallowing disorders after treatment for oral and oropharyngeal cancer

Flashcards created for reviewing key concepts of dysphagia related to oral cavity and pharyngeal cancers.

Dysphagia severity

Ranges from mild, transient dysphagia to severe, disabling, and lifelong.

Three primary clinical factors dictating dysphagia

1) Stage of the cancer; 2) Site of the cancer; 3) Type of locoregional therapy (surgery or radiation).

Staging criteria for head and neck cancers

Cancers are staged according to size and location.

Oral cavity subsites count

The oral cavity comprises seven subsites.

Pharyngeal cancer sites

Staging is divided into nasopharyngeal, oropharyngeal, and hypopharyngeal.

Criteria for staging head and neck tumors

Tumor size (T), nodal status (N), presence or absence of distant metastasis (M).

Primary tumor size assignment

False; the primary tumor size is assigned a number from 1 to 4, with T1 being the smallest and T4 the largest lesion.

Cancer confinement indicator

M0 indicates cancer confined to the head and neck region; M1 indicates distant spread.

Common metastasis site for HNC

Most commonly metastasize to the lung.

Primary treatment modalities for oral and pharyngeal cancers

Surgical resection or radiotherapy (RT).

Primary treatment for oral cavity cancers

Oral cavity cancers are primarily treated surgically.

Nonsurgical protocols for pharyngeal cancers

These are referred to as organ preservation methods.

Five characteristics predicting surgical injury to swallowing

1) Location (tumor site); 2) Size (T stage) of resection; 3) Surgical approach; 4) Closure technique; 5) Surgical management of the neck.

Surgical margin requirement

The malignant tumor must be resected along with a margin of at least 1.5 to 2 cm of normal tissue.

Type of surgery including multiple structures

Composite resection.

Preferred resection type for avoiding injury

Transoral resection.

Surgical requirement for larger posterior oral cavity tumors

Open surgeries are required.

Timing for radiotherapy as an adjunct to surgery

Usually given postoperatively for advanced-stage disease.

Surgery for recurrent cancer

Salvage surgery.

Goal of surgical closure

To restore structure and function of the operative site.

Healing by secondary intention defined

When the wound is left open to remucosalize and scar in its own without suture or surgical closure.

Common closure type after small glossectomy

Primary closure.

Definition of a flap

A piece of tissue that has been elevated or raised away from its normal site.

Pedicled flap defined

A flap that is left attached to the vasculature of the donor site.

Types of pedicled flaps

Local and distal flaps.

Radical neck dissection defined

Removes submandibular lymph nodes and lymph nodes in the lateral neck (levels I to V).

Postoperative consequence of selective neck dissection

False; significant dysphagia is not expected.

Glossectomy defined

Surgery to resect tumors of the tongue.

Types of glossectomies

1) Partial glossectomy; 2) Hemiglossectomy; 3) Subtotal glossectomy; 4) Total glossectomy.

Function affected in total glossectomy patients

Lingual propulsion and bolus control are reduced.

Dump swallow technique defined

When the supraglottic swallow is coupled with a posterior head tilt.

Use of utensils in glossectomy

Helps manipulate food over to the teeth for mastication.

Mandibulectomy defined

Surgical resection of a portion of the mandible.

Marginal mandibulectomy defined

Leaves the outer or lower rim of the mandible intact.

Segmental mandibulectomy defined

Removes a full segment of the mandible anywhere along the bone.

Effect of anterior floor-of-mouth resection on swallowing

False; the oral phase of the swallow is usually normal.

Maxillectomy defined

Surgical procedure to remove tumors of the hard palate, maxillary sinuses, and/or nose.

Effect of hard palate resection

Disrupts the oronasal seal.

Result of palatal resections

Causes velopharyngeal insufficiency.

Common sites for oropharyngeal cancer

Usually arise in the tonsil and base of tongue.

Significant dysphagia symptoms after transoral surgery

Strongly correlated with pain.

Tonsillectomy defined

Surgical removal of the palatine tonsil.

Current standard surgery for tonsillar cancer

Transoral radical tonsillectomy or lateral oropharyngectomy.

Base-of-tongue resection defined

Removes a portion of the posterior tongue behind the circumvallate papillae.

Radiotherapy function

Uses ionizing radiation to kill rapidly dividing cancer cells.

Types of RT toxicities

Acute and late.

Primary drivers of late toxicity from RT

Fibrosis, chronic inflammation, vascular damage.

Effects of radiation side effects

Reduce desire and ability to eat.

Xerostomia defined

Altered composition of saliva and reduced saliva flow.

Treatments for xerostomia

1) Topical saliva substitutes; 2) Acupuncture; 3) Systemic agents.

Mucositis defined

Ulceration of the mucosal lining in the oral and pharyngeal cavities.

Odynophagia defined

Painful swallowing.

Dysgeusia defined

Altered or impaired taste.

Result of damage to blood vessels in irradiated areas

Fibrosis.

Denervation explained

Late effect of RT causing cranial neuropathies.

Stricture defined

Luminal narrowing of the pharyngoesophageal segment or esophageal inlet.

Trismus defined

Decreased mouth opening due to injury.

Post-treatment feature of dysphagia

Decreased range of motion (ROM) in the pharyngeal phase.

Features of Radiation-Associated Dysphagia (RAD)

1) Delay in pharyngeal swallow reaction time; 2) Reduced contraction and movement; 3) Residue causing aspiration.

RAD development

True; it can develop during treatment or years later.

Baseline swallowing evaluation measures

1) Videofluoroscopy or endoscopy; 2) Rating scale of oral intake; 3) ROM measures; 4) PRO measures; 5) Lingual strength.

Pretreatment counseling defined

Best practice standard for existing swallowing disorders.

Postoperative swallowing intervention initiation

When suture lines have healed sufficiently.

Hierarchy for swallowing therapy parts

1) Saliva management; 2) Resuming safe oral intake; 3) Increase volume then complexity; 4) Use it or lose it; 5) Transitioning to survivorship.

Independent saliva management training

Can begin prior to clearance for oral trials.

Oral intake readiness factors

1) Surgical site must be healed; 2) Oropharyngeal swallow must be safe.

Optimal test for oral intake readiness

Videofluoroscopy.

First swallow study goal post-surgery

To identify safe means for resuming oral intake.

Volume and complexity focus after intake increase

Once the patient increases the volume, focus shifts to increasing complexity.

Primary goals of proactive swallowing therapy during RT

1) Eat- maintaining oral intake; 2) Exercise- adherence to swallowing exercises.

“Use it or lose it” philosophy definition

True; it's the treatment philosophy during and after RT.

Goals of 'pre-habilitation' therapy

1) Safe oral intake throughout RT; 2) Accuracy and adherence to HEP.

Optimal rehabilitation team professionals

Oncologists, nursing providers, psychosocial specialists, dentists, rehabilitation specialists, dietitians, speech-language pathologists.

Increased dental disease risk after RT

Due to diminished salivary flow and altered composition; risk of osteoradionecrosis.