The Benefits of Instrumental Evaluations for People with Head and Neck Cancer

The speech-language pathologist (SLP) plays a critical role in head and neck cancer interdisciplinary team. Current research demonstrates that patients with head and neck cancer are at risk for the development of acute and chronic ramifications due to cancer itself, as well as subsequent treatment modalities utilized to eradicate the disease. Instrumental evaluations, the modified barium swallow study (MBSS) and flexible endoscopic evaluation of swallowing (FEES) are gold standard tools in identifying the presence of dysphagia, determining severity, delineating impairments, creating individualized care plans, assessing the effects of compensatory strategies, and analyzing the impacts of therapuetic interventions.

I created the blog below for the purposes of education and advocacy for those with head and neck cancer. My hope is that this information will helpful for SLPs striving towards improved care for this patient population.

Patients may have dysphagia at baseline prior to intervention for head and neck cancer, often experience acute toxicities during treatment, and frequently develop chronic dysphagia.

• Current literature indicates that a variety of causes can alter swallow function, including the tumor itself, treatment modalities utilized to treat the disease, and subsequent acute and chronic side effects (Deng et al., 2011; Smith et al., 2015.)

• Ranta et al. (2021) stated that late toxicities of radiation therapy for head and neck cancer are “common,” with 45% of individuals in their retrospective analysis reporting chronic dysphagia. 

• Ranta and colleagues (2021) further reported that radiation therapy to the neck increased the risk for chronic dysphagia. 

• Dewan (2020) stated that chemotherapy agents often result in toxicity and mucositis, and stomatitis, in turn, adding to or resulting in dysphagia,

• Kronenberger and Meyers (1994) found that surgical resection in head and neck cancer results in consistent presentations of dysphagia and aspiration because of the anatomical changes. 

• Both MBSS and FEES are considered gold-standard options in identifying the presence and severity of dysphagia (Langmore et al., 2022; Martin-Harris et al., 2020).

Benefits of MBSS

• MBSS is used to assess swallow function across the continuum including the oral, pharyngeal and esophageal stages (Martin-Harris et al., 2020; Martin-Harris et al., 2021; Gregor, 2023).

• Swallow dysfunction can be caused by downstream issues demonstrating the need for esophageal visualization which can only be obtained via MBSS (Gregor, 2023). 

• Recommendations for the management of oropharyngeal dysphagia may result in downstream ramifications, further demonstrating the vitality of swallow assessment across the continuum (Gregor, 2023).

• People with head and neck cancer frequently develop oropharyngeal dysphagia, with literature citing prevalence upwards of 45% - this further demonstrates the need for assessment across the continuum (Krebbers et al., 2023).

Benefits of FEES

• FEES can be utilized to assess for internal fibrosis (Groher & Crary, 2021). 

• FEES allows clinicians to make recommendations and interpretations regarding edema progression. Modified barium swallow studies (MBSS) do not allow the clinician to assess tissue integrity (i.e. coloring, progression through lymphatic continuum, etc.)

• FEES can be utilized in any setting, allowing the clinician to come to the patient.

• There is no radiation exposure, which can be a concern especially for those with HNC despite the guidelines of “as low as reasonably achievable” (ALARA) (Fazel et al., 2009; Langmore et al., 1988).

• Patients with head and neck cancer often have chronic dysphagia, meaning that repeated instrumental evaluations may be needed. Use of FEES can help meet this need, again with reduced exposure to radiation long-term.

• Patients may have sensory changes due to head and neck cancer and/or its subsequent treatments. Clinicians can utilize FEESST to assess both motor and sensory components of swallowing (Aviv et al., 1998).

• There are no timeline requirements, meaning that the clinician can assess aspects of swallowing and oral intake unachievable with MBSS including maintenance of strength, speed, and endurance over the course of a meal (Leder & Murray, 2008).

• Clinicians can utilize normal foods and liquids and are able to administer items of the patient’s preference compared to the need to utilize barium consistency with MBSS.

• FEES allows for the assessment of secretion management (Murray et al., 1996).

• FEES allows for vocal fold screening.

• Optimal visualization of the larynx (Kelly et al., 2006).

• Current literature indicates that FEES is easy to perform and may be more economical than videofluoroscopic swallowing studies (Warnecke et al., 2009).

• FEES is beneficial in the evaluation of residue (Farneti, 2008).

• FEES is “a sensitive tool for detecting laryngeal penetration and aspiration” (Leder & Murray, 2008).

• It is the responsibility of the speech pathologist to identify the pathophysiology resulting in dysphagia (Langmore et al., 2022; Martin-Harris et al., 2020). 

References

Aviv, J. E., Kim, T., Sacco, R. L., Kaplan, S., Goodhart, K., Diamond, B., & Close, L. G. (1998). FEESST: a new bedside endoscopic test of the motor and sensory components of swallowing. The Annals of Otology, Rhinology, and Laryngology, 107(5 Pt 1), 378–387. https://doi.org/10.1177/000348949810700503

Deng, J., Ridner, S. H., & Murphy, B. A. (2011). Lymphedema in patients with head and neck cancer. Oncology Nursing Forum, 38(1), E1–E10. https://doi.org/10.1188/11.ONF.E1-E10

Dewan, K. (2020). Chemotherapy and dysphagia: the good, the bad, the ugly. Current Opinion in Otolaryngology & Head and Neck Surgery, 28(6), 385–391. https://doi.org/10.1097/MOO.0000000000000672

Farneti D. (2008). Endoscopic scale for evaluation of the severity of dysphagia: preliminary observations. Revue de laryngologie - otologie - rhinologie, 129(2), 137–140.

Fazel, R., Krumholz, H. M., Wang, Y., Ross, J. S., Chen, J., Ting, H. H., Shah, N. D., Nasir, K., Einstein, A. J., & Nallamothu, B. K. (2009). Exposure to low-dose ionizing radiation from medical imaging procedures. The New England journal of Medicine, 361(9), 849–857. https://doi.org/10.1056/NEJMoa0901249

Gregor, J. (2023). The importance of looking at the REST of the swallow in patients with head and neck cancer. Perspectives: American Journal of Speech-Language Pathology, 8 (5), 1097-1102. https://doi.org/10.1044/2023_PERSP-23-00055

Groher, E., & Crary, M. A. (2021). Dysphagia Clinical Management in Adults and Children (3rd ed.) Elsevier. 

Kelly, A. M., Leslie, P., Beale, T., Payten, C., & Drinnan, M. J. (2006). Fibreoptic endoscopic evaluation of swallowing and videofluoroscopy: does examination type influence perception of pharyngeal residue severity?. Clinical Otolaryngology : Official Journal of ENT-UK ; Official Journal of Netherlands Society for Oto-Rhino-Laryngology & Cervico-Facial Surgery, 31(5), 425–432. https://doi.org/10.1111/j.1749-4486.2006.01292.x

Krebbers, I., Pilz, W., Vanbelle, S., Verdonschot, R. J. C. G., & Baijens, L. W. J. (2023). Affective symptoms and oropharyngeal dysphagia in head-and-neck cancer patients: A systematic review. Dysphagia, 38(1), 127–144. https://doi.org/10.1007/s00455-022-10484-8

Kronenberger, M. B., & Meyers, A. D. (1994). Dysphagia following head and neck cancer surgery. Dysphagia, 9(4), 236–244. https://doi.org/10.1007/BF00301917

Langmore, S.E., Schatz, K. & Olsen, N. (1988). Fiberoptic endoscopic examination of swallowing safety: A new procedure. Dysphagia, 2, 216-219.

Langmore, S. E., Scarborough, D. R., Kelchner, L. N., Swigert, N. B., Murray, J., Reece, S., Cavanagh, T., Harrigan, L. C., Scheel, R., Gosa, M. M., & Rule, D. K. (2022). Tutorial on clinical practice for use of the fiberoptic endoscopic evaluation of swallowing procedure with adult populations: Part 1. American Journal of Speech-Language Pathology, 31(1), 163–187. https://doi.org/10.1044/2021_AJSLP-20-00348

Leder, S.B. & Murray, J.T. (2008). Fiberoptic endoscopic evaluation of swallowing. Phys Med Rehabil Clin N Am, 19, 787-801.

Martin-Harris, B., Canon, C. L., Bonilha, H. S., Murray, J., Davidson, K., & Lefton-Greif, M. A. (2020). Best practices in modified barium swallow studies. American Journal of Speech-Language Pathology, 29(2S), 1078–1093. https://doi.org/10.1044/2020_AJSLP-19-00189

Martin-Harris, B., Bonilha, H., Brodsky, M., Francis, D., Fynes, M., Martino, R., O'Rourke, A., Rogus-Pulia, N., Spinazzi, N., Zarzour, J. (2021). The modified barium swallow study for oropharyngeal dysphagia: Recommendations from an interdisciplinary expert panel. Perspectives of the ASHA Special Interest Groups. 6. 1-10. 10.1044/2021_PERSP-20-00303.

Murray, J, Langmore, S.E., Ginsberg, S. & Dostie, A.(1996). The significance of oropharyngeal secretions and swallowing frequency in predicting aspiration. Dysphagia, 11, 99-103.

Ranta, P., Kytö, E., Nissi, L., Kinnunen, I., Vahlberg, T., Minn, H., Haapio, E., Nelimarkka, L., & Irjala, H. (2021). Dysphagia, hypothyroidism, and osteoradionecrosis after radiation therapy for head and neck cancer. Laryngoscope Investigative Otolaryngology, 7(1), 108–116. https://doi.org/10.1002/lio2.711

Smith, B. G., Hutcheson, K. A., Little, L. G., Skoracki, R. J., Rosenthal, D. I., Lai, S. Y., & Lewin, J. S. (2015). Lymphedema outcomes in patients with head and neck cancer. Otolaryngology--Head and Neck Surgery : Official Journal of American Academy of Otolaryngology-Head and Neck Surgery, 152(2), 284–291. https://doi.org/10.1177/0194599814558402