Changes in the treatment of advanced laryngeal cancer have necessitated a closer look at the rehabilitation process of patients who undergo laryngectomy or laryngopharyngectomy, with a particular focus on the swallowing abilities of each population.

The prevalence of dysphagia in the laryngectomy and laryngopharyngectomy populations tends to be underreported and overlooked, said Andrew Palmer, MS, CCC-SLP, an instructor at the Northwest Clinic for Voice and Swallowing, Oregon Health & Science University (OHSU), in Portland.

"We tend to associate dysphagia with aspiration; and since aspiration is pretty uncommon after laryngectomy, it's a question that doesn't tend to get asked," Palmer told ADVANCE. "Therefore, it is generally underrepresented in the literature."

Currently, the seminal study in otolaryngology literature addressing the prevalence of dysphagia in the laryngectomy population is usually referred to simply as the "VA study." The study involved 166 patients with laryngeal cancer who had undergone chemoradiation and 166 who had had a laryngectomy with radiation. Researchers followed the patients for several years to monitor their recovery. Swallowing problems persisted in almost identical percentages in both groups a year or more after surgery.¹

Until recently, treatment for advanced laryngeal cancer almost always included a surgical intervention such as laryngectomy, Palmer noted. Today, patients may have the option of chemoradiation.

"If patients are cured by the chemoradiation alone, they don't need surgery," he explained. "Those who aren't cured by the chemoradiation subsequently undergo a 'salvage laryngectomy.'" They may have remaining cancer cells or a severely weakened larynx caused by the chemoradiation.

"People who have undergone one significant intervention and subsequently go through a laryngectomy have the most problems and ultimately need the most aggressive rehabilitation," he said. "A lot of people continue to have significant problems at least six months after surgery and often through the first year. That hasn't been the case historically, but it is going to be now that we put many people through more than one significant intervention."

Palmer recently completed a study with colleagues Christine Chambers, MS, a fellow at the Portland VA Medical Center and Donna Graville, PhD, CCC-SLP, of OHSU, comparing the swallowing function of patients with total laryngectomy and those who had undergone a laryngectomy with a partial pharyngectomy using radial forearm free tissue transfer reconstruction.

"Dysphagia is almost an index of how well rehabilitated somebody may be after surgery because the same mechanism is responsible to some extent for both swallowing and speaking after laryngectomy," Palmer stated. "Patients who have swallowing problems often have communication problems, may have respiratory difficulties, and often are more compromised overall."

The researchers monitored 22 patients who had undergone typicallaryngectomies and eight patients who had laryngectomies with partial pharyngectomies using tissue from the radial forearm for the reconstruction. All of the patients who had undergone a pharyngectomy had received radiation, compared to 68 percent of the laryngectomy group.

The dysphagia-related, quality-of-life rates were similar in both groups for over a year after treatment, the researchers found, but each group was prone to certain post-operative complications. Rehabilitation for patients who underwent a laryngectomy tended to center on management and compensation, with the possible inclusion of additional surgical interventions.

Patients who developed a stricture-a band of scar tissue that usually develops around the cervical esophagus-were at risk for experiencing severe swallowing difficulties, Palmer said. "The narrowing can get so tight that only liquids may go down. The person may have a lot of difficulty with pills and solids. If you catch it relatively early, that tends to be something that can be very easy to manage."

Of the patients involved in the study, 38 percent who had undergone a pharyngectomy reported that they had developed a stricture requiring periodic dilation. None of the patients in the total laryngectomy group reported developing strictures.

Surgical treatment for a stricture requires that a set of dilators be passed down the esophagus to stretch open the scar tissue. Strictures severely limit any gains the patient makes in rehabilitation, but too often this course of treatment is overlooked as a possible etiology of dysphagia, Palmer said.

"When we teach courses for grad students, we tend to say that if somebody with radiation has dysphagia, the first thing to rule out is a stricture because it's one of the easiest things to intervene for," he said.

During the healing process, some patients develop a pouch in the throat alternately referred to as a pseudodiverticulum or pseudoepiglottis.

"On X-ray it can look exactly like a valeculae with an epiglottis in the throat, and that can cause food and liquid to hang up," Palmer explained. A surgeon sometimes uses a laser or scalpel to transect the band of scar tissue to allow foods and liquids to drain into the throat.

Dysphagia may occur in some patients who have cricopharyngeal spasms. These spasms, which occur in the upper esophageal sphincter, may be so severe as to cause swallowing difficulties. In the most severe cases the spasms may be treated by Botox injections to relax the muscle or by myotomy, which involves cutting some of the muscle fibers to aid in the transit of food and liquids.

Among other interventions for patients with dysphagia is a non-surgical, diet-centered treatment. Patients may alternate foods and liquids or avoid challenging food consistencies.

"A lot of our patients experience reflux or regurgitation symptoms," Palmer explained, "so we put them on the same protocol as people with GERD [gastroesophageal reflux disease] or poor esophageal motility: keeping them upright for at least an hour after eating or drinking; avoiding spicy, acidic or caffeinated foods, which tend to promote more reflux; and elevating the head of the bed at night."

Another intervention that has helped some people is chewing a stick of a sugar-free chewing gum after meals, he noted. This helps to neutralize some of the stomach acid and speed digestion.

Some interventions are coordinated with a dentist, dietician or other medical processional if related issues seem to be contributing to an individual's inability to eat and drink normally.

Patients who have undergone a reconstruction of the pharynx tend to be the most compromised simply because of the nature of the treatments they haveendured, Palmer said. "Patients who had chemoradiation before surgery may have a compromised immune system, and they tend to have less energy and be nutritionally compromised." As a result, "they may be sicker before surgery, and that plays out in their healing time."

This patient group may require tube feeding for a longer period of time. One of the most common post-operative problems these patients encounter is developing a fistula, an inadequately healed opening in the neck or under the chin.

Half of the patients in the pharyngectomy group in the study conducted by Palmer and his colleagues developed a fistula, compared to just 18 percent of the laryngectomy group.

"That can be a really frustrating problem for many people who have gone through the reconstruction," he said. "This is a big surgery, and they may not be able to take any nutrition until their doctor clears them. Once that fistula is healed, they tend to have more problems with post-operative swelling. Until the swelling goes down, they may be on a very modified diet of liquids and pureed or soft foods."

Even a year after surgery 50 percent of the pharyngectomy group still reported dietary restrictions, while only 14 percent of the total laryngectomy group had restrictions.

"Both groups seemed to have adapted to their deficits quite well, but both reported that swallowing wasn't normal even a year out," he noted.

The OHSU study focused on patients who underwent radial forearm flap reconstructions. Pharyngeal reconstruction also may use tissue from the chest, back or jejunum. Since tissue from these areas is not an exact match to the original, feeding and swallowing problems may occur. A propulsion problem may occur, with fluids tending to hang up and go down more slowly.

Problems may be avoided by alternating liquids with solids, but clinicians should be aware that a stricture is more likely to form after a reconstruction, Palmer advised. "A lot of these patients need dilation periodically to keep the pharynx from closing down and becoming obstructed. People who are having laryngectomies these days need more aggressive intervention from speech pathologists and need more rehabilitation because they tend to be more compromised before they even start."

Reference

1. Hillman, R.E., Walsh, M.J., Wolf, G.T., et al. (1998). Functional outcomes following treatment for advanced laryngeal cancer. Annals of Otology, Rhinology, and Laryngology (Suppl.), 107: 2-27.

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