Clinical Decision Making with Head and

Neck Cancer Patients with Dysphagia

Heather Starmer, M.A., CCC-SLP, BCS-S1,2 and
Jeffrey Edwards, M.S., CCC-SLP3

ABSTRACT

Dysphagia is a common challenge faced by patients with

head and neck cancer. Management of these patients is quite distinct
from many other dysphagia etiologies due to the nature of surgical

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removal of organs critical to swallowing, the ability to provide
preventative therapies, and the variable risk for complications related
to dysphagia. Thus, clinicians providing care to the head and neck
cancer population need to understand these differences when
employing clinical decision making. In addition, changes in the
demographics of head and neck cancer, related predominantly to
the epidemic of oropharyngeal cancer associated with the human
papillomavirus, have further transformed both the types of patients
and the types of treatments offered. These epidemiologic factors
further complicate the decision-making process for clinicians. This
article provides a framework for decision making in the surgical and
nonsurgical patient with head and neck cancer.

KEYWORDS: dysphagia, head and neck cancer, radiation therapy,

radiation-associated dysphagia, rehabilitation, swallowing therapy

Learning Outcomes: As a result of this activity, the reader will be able to (1) discuss how patients with head
and neck cancer differ from other populations with dysphagia; (2) apply critical thinking in selecting appropriate
assessment tools for evaluating dysphagia in patients with head and neck cancer; and (3) implement a risk-
stratified decision-making schema for determining when patients with head and neck cancer should receive a
feeding tube.

1
Department of Otolaryngology – Head and Neck Surgery,
Stanford University, Palo Alto, California; 2Head and Neck
Speech and Swallowing Rehabilitation, Stanford Cancer
Center, Palo Alto, California; 3Clinical Speech-Language
Pathologist, Stanford Cancer Center, Palo Alto, California.
Address for correspondence: Heather Starmer, M.A.,
CCC-SLP, BCS-S, Department of Otolaryngology –
Head and Neck Surgery, Stanford University, 900 Blake
Wilbur Drive, Suite 3025, Palo Alto, CA 94305
(e-mail: hstarmer@stanford.edu).
Clinical Decision Making in Dysphagia; Guest Editors,
Gary H. McCullough, Ph.D., CCC-SLP and Balaji
Rangarathnam, Ph.D., CCC-SLP.
Semin Speech Lang 2019;40:213–226. Copyright
# 2019 by Thieme Medical Publishers, Inc., 333 Seventh
Avenue, New York, NY 10001, USA. Tel: +1(212) 584-
4662.
DOI: https://doi.org/10.1055/s-0039-1688979.
ISSN 0734-0478.
213
214 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 40, NUMBER 3
T he management of patients with head
and neck cancer (HNC) has remarkably chan-
ged in the last decade and a half, keeping in line
with the biological and epidemiological nature
of HNC. Along with these changing disease
trends, de-escalation approaches to treatment,
supported by technological advances in surgi-
cal/medical treatments (e.g., intensity modula-
ted radiation therapy, transoral robotic-assisted
surgery), have improved functional outco-
mes.1,2 Historically, prognosis with HNC was
poor due to a history of heavy alcohol and
tobacco use. Treatments often involved radical
surgical resection with significant functional
morbidity, and wide-field radiotherapy with
significant acute and late toxicities to critical
structures for speech and swallowing.3,4 While
alcohol- and tobacco-associated cancers have
declined in the United States, the incidence of
HPV-related cancers of the head and neck
continue to rise.5 These patients are younger,
healthier, and do not have the same alcohol-
and tobacco- related risks seen in prior genera-
tions and are more likely to be cured from
treatment.6,7 As a result, these patients have
different expectations of survivorship following
their treatment, including the need to resume
typical vocational, social, and family responsi-
bilities and retain an acceptable quality of life—
for many more years than historically observed
in the HNC population.8 Given the increased
life expectancy for many of these patients
compared with previous generations, simply
surviving is an inadequate outcome. As such,
these patients require knowledgeable swallo-
wing rehabilitation specialists in addition to
skilled radiation, medical, and surgical oncolo-
gists, exemplified frequently in multidiscipli-
nary care contexts.9–11 While multidisciplinary
HNC clinics facilitate interprofessional com-
munication and coordination of care, these
clinics tend to be more common in tertiary
care centers than in community or smaller
specialty healthcare institutions.
Given the swallowing implications of HNC
and its respective oncological treatments, a
speech–language pathologist (SLP) is a critical
member of the care team and should be involved
from the time of diagnosis or, at the very least,
before the initiation of treatment to maximize
functional outcomes.12,13 With respect to swal-
2019
lowing, early involvement of the SLP allows for a
baseline functional assessment with instrumen-
tation whenever indicated, establishment of
functional outcome measures, intervention,
and patient education before, during, and after
treatment based on a patient’s needs. As such, an
SLP’s involvement throughout the continuum
of patient care promotes best functional out-
comes and best practices in HNC.14,15
The nature of dysphagia in HNC differs
from other dysphagia etiologies (e.g., stroke,
dementia, traumatic brain injury) as concomi-
tant cognitive-linguistic impairments, which
may otherwise interfere with dysphagia treat-
ment approaches, are less-often encountered in
this setting. Patients with HNC-related dysp-
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hagia are unique in that they are usually neuro-
typical at onset, often present with functional
swallowing capacity—or at least adequate func-
tional reserve at baseline, and traditionally pre-
sent with lower risk of pulmonary sequelae
related to aspiration.16 Thus, clinicians provi-
ding care to patients with HNC need to consider
how to alter a treatment approach that necessa-
rily may be more liberal, and in most cases more
proactive, than with other diagnostic groups.
Management approaches to dysphagia in
the HNC setting can be organized into domains
of education and counseling, functional preser-
vation, functional compensation, and functional
restoration (see Table 1). Since many patients
with HNC will encounter functional loss secon-
dary to their oncological treatments, proper
education and counseling is critical to ensure
patients have realistic expectations of their reco-
very and a thorough understanding of the life
impact that may occur with respect to degluti-
tion.17,18 Prehabilitative intervention may be
clinically indicated when the intended outcome
is functional preservation in the setting of a
physiologically disruptive treatment, such as
with oropharyngeal radiotherapy (e.g., prophy-
lactic pharyngeal and masticator exercises).19,20
Restoration-focused rehabilitation efforts may
include a variety of physiologically based inter-
ventions designed to improve structural strength
or range of motion (e.g., linguo-palatal compres-
sion, Shaker exercise, expiratory muscle strength
training [EMST]) and may include a variety of
biofeedback tools (e.g., surface electromyogra-
phy, Iowa Oral Performance Instrument).21–24
 DECISION MAKING HEAD AND NECK/STARMER, EDWARDS 215

Table 1 Management Approaches to Head and Neck Cancer Dysphagia

Description Examples

Education- Education and counseling about functional Pre-laryngectomy counseling,

focused loss and/or changes from treatment or late radiation-associated dysphagia
disease with respect to deglutition
Prehabilitation- Functional preservation in the setting of Prophylactic swallowing exercises during
focused expected decline in function radiation therapy
Restoration- Restore/improve functional range of Shaker exercise and EMST for therapy
focused motion, strength, and coordination given targeting suprahyoid musculature and
impairment improving hyolaryngeal elevation
Compensatory- Augment typical swallowing patterns to Supraglottic swallowing for aspiration
focused improve pulmonary safety or improve after partial laryngectomy; respiratory-
efficiency swallow retraining for late-radiation
associated dysphagia
Surveillance- Routine swallowing imaging or clinical Annual instrumental swallowing
focused evaluation after acute treatment toxicities evaluation following radiation therapy for

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have subsided a tongue base tumor

Abbreviation: EMST, expiratory muscle strength training.

Compensation-based intervention (e.g., swallo-
wing strategies, respiratory-swallowing retrai-
ning) may alternatively be indicated when
there is limited prognosis of return to normal
functioning, a clear immediate need to improve
pulmonary safety or bolus flow parameters, or
when there has been a limited response to
restoration-focused interventions, such as in
the case of late radiation-associated dysphagia
(RAD).22,25 Finally, ongoing swallowing surveil-
lance with imaging is essential for patients at risk
for developing late effects from radiation therapy
after acute toxicities have subsided, particularly
with oropharyngeal cancer patients—given func-
tional complications of trismus, soft-tissue fib-
rosis, and cranial nerve denervation which may
not develop until years after treatment.26 In such
patients, early identification and intervention
may change the outcome trajectory in high-risk
patients (e.g., identifying and managing silent
aspiration before a pulmonary complication may
develop).
SLP MANAGEMENT OF THE
SURGICAL HEAD AND NECK
CANCER PATIENT
Management of the surgically treated patients
with HNC with dysphagia requires risk strati-
fication and interventions that prioritize shared
decision making, education, and patient advo-
cacy. The SLP must have a thorough under-
standing of their patient’s global functional
status and demographic-based risks (e.g., using
geriatric health screening tools) to not only allow
for a comprehensive assessment but also to
develop a patient-centered care plan.27,28 Risk
stratification begins by understanding the
disease-involved swallowing structures, the
expected surgical plan, and baseline swallowing
symptoms to determine whether a clinical
assessment of swallowing risk or instrumental
swallowing examination is indicated. In many
cases, a presurgical instrumental baseline assess-
ment will assist the treating medical/surgical
teams in making the most functionally aligned
treatment recommendations (e.g., assessing
function prior to consideration of organ-sparing
treatment for laryngeal cancer, or identifying
silent aspiration in a patient who reports normal
swallowing at baseline).29,30
There are numerous useful, evidence-based
tools available when evaluating swallowing risk
and developing care goals, including patient-
and clinician-reported outcome measures (e.g.,
the MD Anderson Dysphagia Inventory
[MDADI] or the Functional Oral Intake Scale
[FOIS]),31–33 standardized assessment tools
(e.g., Mann Assessment of Swallowing Ability—
Cancer [MASA-C] or the Modified Barium Swal-
low Study Impairment Profile [MBSImP]),34,35 as
well as objective measure of lingual range of
216 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 40, NUMBER 3
motion33 and maximal interincisal distance.36
Together with a thorough chart review and
patient interview, these tools will assist clinicians
in determining whether swallowing visualiza-
tion is indicated and which instrumentation is
favored (e.g., endoscopy vs. fluoroscopy).37,38
For many patients with HNC, instrumentation
is clearly favored (e.g., resections of the oropha-
rynx, laryngopharynx, and hypopharynx). In
others, such as patients with small tumors of
the anterior oral cavity (e.g., labial, buccal, and
anterior one-third of oral tongue), instrumental
baseline assessment may not be as clinically
necessary due to less potential for baseline impact
on pharyngeal swallowing safety and efficiency.
However, there are functional implications for
swallowing safety and efficiency associated with
oral cavity resections. Therefore, it remains
important for the SLP to at least clinically assess
and educate the patient undergoing oral cavity
resections prior to surgery. Surgical resections
interrupting the floor-of-mouth or suprahyoid
musculature and those necessitating flap
reconstruction come with increased risk of aspi-
ration and extended length of recovery, as oppo-
sed to a small, focal, oral resection with a primary
closure or locally advanced tissue flap.39–41 In
patients deemed high risk for pulmonary com-
plications arising from aspiration (e.g., those
with chronic obstructive pulmonary disease),
clinicians might also consider baseline pulmo-
nary measures such as vital capacity, peak expi-
ratory pressure, and cough reflex testing.42
While humble, a simple peak flow meter and
disposable filters can be a meaningful addition to
the dysphagia clinician’s toolset.
Surgical patients should be active partici-
pants in setting goals and priorities for swallo-
wing rehabilitation. Given that patients arrive
to these conversations with their own personal
hopes and expectations for quality of life, the
SLP should be a partner, using his or her
experiential, research, and theoretical know-
ledge to provide scaffolding for rehabilitation
goals. At times, these perspectives may conflict;
however, it is the ethical duty of the SLP to
always respect patient autonomy. For example,
some patients may find it acceptable to maintain
adequate nutrition with a combination of
enteral feeding and oral intake, while others
may find a feeding tube unacceptable and prefer
2019
to maintain dietary restrictions and multiple
swallowing strategies.
While patient preference is one factor that
may influence treatment, rehabilitation goals
may also be constrained by surgeon-mandated
range of motion and functional use restrictions.
This may include limited PO or NPO orders,
particularly in patients undergoing free flap
reconstruction, though there is emerging evi-
dence supporting early reinitiation of PO
intake.43–45 In some cases, patients may
undergo salvage resection and reconstruction
after recurrence or organ failure following defi-
nitive nonsurgical treatments (e.g., functional
laryngectomy with the goal of improved swal-
lowing-related quality of life).46,47 Regardless
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as to the specifics of the surgery, the SLP plays a
primary role in guiding patients through the
process of realistic expectation setting related to
functional changes, expected rehabilitation
needs, and timelines while providing appro-
priate education and counseling to ensure ade-
quate patient knowledge is gained.48
Postoperative rehabilitation may vary
depending on the aforementioned factors as
well as the interval since surgery. Intervention
goals in the acute postoperative period may
include training of strategic maneuvers to faci-
litate bolus control or airway safety. Or, in more
complex cases, acute goals may simply be to
identify whether the patient can safely initiate
some type of PO intake to minimize the
potential for disuse atrophy. Postacute goals
in the outpatient clinic often focus more on
comprehensive goals related to restoration of
maximal function whether it be with swallo-
wing-related range-of-motion and strengthe-
ning exercises or behavioral retraining of the
airway-swallowing mechanisms to adapt to an
anatomical loss (e.g., partial laryngectomy).49,50
Additionally, there are times when it is apparent
that additional evaluation and treatment needs
are indicated and fall outside of the SLP’s scope
of practice. This may include situations such as
when nutritional inadequacy is suspected, ina-
dequate coping or resource utilization is suspec-
ted, or when additional medical specialists are
needed to intervene in a patient’s dysphagia
(e.g., gastroenterology or laryngology). Given
the unique and evolving needs of the HNC
patient, it is essential for SLPs to understand
 DECISION MAKING HEAD AND NECK/STARMER, EDWARDS
the roles of the various oncology team members
and the supporting allied health professionals
including registered dieticians, social workers,
rehabilitation specialists, and additional patient
care providers.51
SURGICAL CASE STUDY
A 49-year-old male with type-I diabetes, mild
obstructive sleep apnea, hypertension, and
hyperlipidemia was diagnosed with a T2 N1
p16-postitive squamous cell carcinoma of the
right tonsil characterized as a firm, erythema-
tous, and exophytic mass with clinical, CT-,
and FNA-confirmed involvement of the ipsila-
teral neck. Baseline patient- and clinician-
reported swallowing outcome measures were
obtained and considered normal (i.e., MDADI
score of 100 and FOIS score of 7). Upon exam,
his maximal interincisal opening was 55 mm
and he demonstrated normal lingual, labial,
velar, and buccal sensorimotor function. An
endoscopic swallowing exam found functional
pharyngeal swallowing physiology and laryngo-
pharyngeal sensorimotor function. The patient
returned for presurgical counseling with SLP,
following a shared decision for frontline trans-
oral robotic surgery–assisted right partial oro-
pharyngectomy and ipsilateral neck dissection.
He was evaluated clinically by an SLP 24
and 48 hours postoperatively. Evaluation revea-
led reduced maximal interincisal opening, lin-
gual edema, and reduced range of motion in all
directional planes with sensory loss along the
anterior third of the bilateral oral tongue,
significant odynophagia, and frequent expecto-
ration and oral suctioning of secretions. Obser-
vational PO trials of various liquid consistencies
with postural compensations and swallowing
maneuvers resulted in persistent dysphagic
symptoms necessitating recommendation for
instrumental evaluation. A bedside flexible
endoscopic evaluation of swallowing (FEES)
performed 72 hours postoperatively found post-
cricoid edema, bilateral vocal process granulo-
mas, an expected surgical wound of the right
oropharynx, and pharyngeal edema which obli-
terated the reservoir capacity of the bilateral
pyriform sinuses. There was deep glottic penet-
ration of secretions and postswallow pyriform
sinus spillover resulting in penetration and
217
aspiration of thin and mildly thick liquids
(International Dysphagia Diet Standardisation
Initiative [IDDSI] Level 2). There was also
moderate residue in the vallecula and on the
posterior pharyngeal wall for puree consistency
requiring liquid washes using a double swallow
in a modified supraglottic-swallow technique:
(1) bolus placement in the oral cavity, (2) breath
hold, (3) two successive swallows, and (4) cough
for airway ejection. Mildly thickened liquids
and use of a compensatory swallowing maneu-
vers reduced painful coughing and aspiration.
Given recommendations for supplemental PO
intake with swallowing strategy recommenda-
tions and consistencies of puree, mildly thi-
ckened fluids, and a free water protocol, he
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discharged from the acute care unit with a
nasogastric (NG) feeding tube.
His feeding tube was removed by the sur-
geon 10 days postoperatively and a repeat FEES
in the outpatient clinic was conducted 24 hours
later to allow for a reduction in edema believed
to be related to the feeding tube. Upon presen-
tation to the SLP clinic, he demonstrated mild
cul-de-sac resonance and mild vocal roughness.
Sensory impairment along the anterior bilateral
tongue was stable with return of a functional
lingual range of motion in all directional planes.
Velar movement was mildly asymmetric with
leftward deviation. Maximal interincisal open-
ing, initially 26 mm, increased to 30 mm after a
set of active range-of-motion masticator exer-
cises. FEES revealed complete velopharyngeal
closure, persistent supraglottic penetration of
secretions secondary to pyriform sinus pooling,
stable pharyngeal edema which continued to
obliterate the reservoir capacity of the bilateral
pyriform sinuses, postcricoid hypertrophy, and
persistent bilateral vocal process granulomas.
PO trials of liquids and puree were adminis-
tered given the patient’s reticence to attempt
solids secondary to fear and pain. There was
mid-swallow penetration of all liquids and post-
swallow aspiration of thin liquids from the
pyriform sinuses and postcricoid spillover
through the posterior commissure. Supraglottic
double swallows paired with a chin tuck with
right head rotation eliminated deep penetration
and subsequent aspiration of liquids. Moderate
liquid pyriform sinus residue and mild vallecu-
lar puree residue were reduced by employing
218 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 40, NUMBER 3
multiple swallows and completing a liquid wash
with airway protection maneuvers. The patient
agreed to a PO diet of puree and nectar liquids
with a free water protocol with dietary modi-
fications to reduce pulmonary risk, palliate
odynophagia, and reduce frequency of traum-
atic forces upon the vocal folds secondary to
coughing (to allow the vocal process granulo-
mas to resolve). He was encouraged to return
for a repeat FEES (
4 weeks post-op). The
examination revealed improved airway safety
and pharyngeal efficiency yielding recommen-
dations for a regular diet as comfort allows,
unrestricted liquid intake, and follow-up pre-
paratory counseling, education, and prophylac-
tic exercise training given recommendations for
adjuvant radiation therapy.
SLP MANAGEMENT OF THE
NONSURGICAL HEAD AND NECK
CANCER PATIENT
The majority of patients diagnosed with HNC
will require radiation as part of their cancer
treatment. This may be given following surgery
in an adjuvant setting or as the primary treatment
modality, either with or without chemotherapy.
Acute toxicities during radiation such as painful
mucositis, dysgeusia, and xerostomia may have a
negative impact on patient’s desire to eat and
drink during treatment. As a result, appetite and
oral intake may suffer, placing the patient at
higher risk for development of dysphagia due to
disuse atrophy. Following radiation, patients
have elevated risks of developing dysphagia,
which may be related to muscle weakness,
soft-tissue fibrosis, chronic lymphedema, and/
or cranial neuropathies. Speech pathologists
working with patients receiving radiation the-
rapy should have a solid understanding of acute
and chronic changes related to radiation and how
those may impact swallowing function.
Acute toxicities of radiation may have a
marked impact on patient function during treat-
ment. More severe levels of toxicity are anti-
cipated when patients receive concurrent
chemoradiation in contrast to induction chemo-
therapy followed by radiation or radiation
alone.52 Additionally, patients over the age of
70 years have been shown to have elevated rates
of acute toxicity during treatment leading to
2019
unplanned hospital care (admissions or visits to
the emergency department), dysphagia, and
feeding tube use, particularly when concurrent
chemoradiation is applied.53,54 Patients in these
high-risk groups should be more closely moni-
tored during their treatment for complications
that may influence their intake. The SLP plays a
critical role on the care team in educating
patients about these toxicities and strategies to
manage them.
Chronic radiation-associated swallowing
toxicities are typically related to fibrosis. During
radiation, there is an increase in reactive oxygen
and nitrogen species, which lead to vascular and
parenchymal cell death and tissue damage. The
body’s natural injury response mechanisms lead to
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hyperactivation of transforming growth factor-b
(TGF-b) and subsequent inflammation. Con-
nective tissue growth factor works in conjunction
with TGF-b to induce sustained fibrosis. Fibrotic
connective tissue then encases the nerves and
muscles leading to reduced muscle mobility and
subsequent atrophy. Fibrosis typically occurs
insidiously and progresses gradually in the weeks
or months following completion of radiation.
Lymphedema may further contribute to dyspha-
gia as edematous structures such as the epiglottis
and arytenoids may have limitations in regard to
mobility and displacement.55 In a small subset of
patients, late RAD may arise many years after
completion of radiation. Late RAD is commonly
associated with significant potential for cranial
neuropathies, reduced sensation, pulmonary
complications from chronic aspiration, and diffi-
culty with maintenance of adequate nutrition.
Goals of care for patients undergoing radia-
tion-based treatment are very different than in
many other populations of patients with dysp-
hagia. Although dysphagia intervention is
commonly reactive and restorative, dysphagia
management in the radiation population is pri-
marily prevention based. Thus, the intention of
treatment is prehabilitation rather than rehabili-
tation. This prehabilitation begins with under-
standing the patient’s baseline function and
expectations for function following treatment.
In the head and neck population, subclinical
dysphagia may be identified in approximately
40% of patients prior to treatment. While in
many cases this pretreatment dysphagia is mild, in
patients with more advanced cancers or those
 DECISION MAKING HEAD AND NECK/STARMER, EDWARDS
with unrelated comorbidities, these baseline defi-
cits may influence both oncologic and therapeutic
treatment decisions. Thus, we would advocate for
pretreatment instrumental assessment of swallo-
wing function to better define baseline function
and to determine which patients may be at
elevated risk for development of dysphagia during
radiation treatment.
Risk stratification is an important aspect of
care of the HNC population and should be
based on knowledge of factors associated with
dysphagia-related complications and thorough
understanding of an individual patient’s capa-
bilities and functional reserve. Both videofluo-
roscopy and endoscopic swallowing assessments
may be used effectively in the pretreatment
setting to ascertain baseline function. Those
patients with baseline dysphagia will be at
elevated risk for dysphagia-related complica-
tions during radiation including feeding tube
dependence and admission for presumed aspi-
ration pneumonia. Such patients warrant close
follow-up with the SLP throughout their treat-
ment course. The goals of care in this subgroup
will be to provide education regarding warning
signs and symptoms of dysphagia, to monitor
for changes that may increase risk of complica-
tions, to apply compensatory strategies and
modifications as needed, and to offer rehabili-
tative care as appropriate. Patients presenting
without baseline changes to their swallowing
mechanism may need less direct clinician moni-
toring and compensatory adaptations. In this
population, a key goal of care is educating
patients about the risks for future dysphagia.
Without understanding the importance of pre-
vention, adherence to clinician recommenda-
tions may suffer. A major goal of care for all
patients receiving radiation is thorough educa-
tion regarding treatment toxicities that may
influence the patient’s ability to maintain oral
intake and complete prophylactic exercises, as
well as strategies to manage those side effects.
Goals of care will necessarily shift in the
postradiation setting. In patients who have
recently completed radiation and have not
presented with significant dysphagia to date,
goals are focused on maintenance of function
and education regarding signs that are indica-
tive of worsening swallow function. In patients
who demonstrate changes to their swallowing
219
mechanism in the first 1 to 2 years following
treatment, the primary goals will be rehabilita-
tion and restoration of function to the greatest
extent possible. For those patients who develop
late RAD, restoration of function may not be an
appropriate goal of care given poor efficacy of
rehabilitative exercises in this population. Skill-
based interventions and compensations may be
more appropriate in the late RAD setting.
Regardless of the specific goals of care the
SLP is addressing, education remains a corner-
stone of SLP intervention across the different
subpopulations of radiation patients. Such edu-
cation can serve to mitigate patient fear and
anxiety, enhance adherence to treatment recom-
mendations, and empower patients to be active
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participants in their health care. Initial education
prior to radiation will focus on education regar-
ding treatment toxicities, how to manage them,
and how they may contribute to long-term
swallowing issues if left unchecked. Specific
treatment-related toxicities that should be
addressed with patients prior to treatment due
to their potential impact on oral intake include
pain, dry mouth, and taste changes. For many
patients, during radiation their relationship with
food may shift from a pleasurable experience to a
burdensome, unpleasant experience. It is impor-
tant for the SLP to acknowledge this at the early
stage of treatment and to provide the patient with
information about why maintaining oral intake is
critical from a nutritional and a long-term swal-
low function perspective.
Pain in particular may have a dramatic
impact on patient adherence to oral intake and
prophylactic exercise protocols. Pain and fear of
pain were cited as primary contributors to non-
adherence in the Pharyngocise study.19 Radia-
tion is known to produce both nociceptive and
neuropathic pain. Unfortunately, narcotic anal-
gesics do not address the neuropathic aspect of
pain. Thus, treatment teams need to consider
alternative pain management strategies to add-
ress the neuropathic aspect of pain as well.
Gabapentin has been shown to successfully
minimize patient pain and narcotic use during
radiation and has been associated with favorable
short- and long-term swallowing outcomes.56,57
The SLP can play an important role in educating
patients as to why it is important to prophylac-
tically start neuropathic pain medications.
220 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 40, NUMBER 3
In addition to addressing pain, the SLP
should also provide education regarding the
injury of the salivary glands during radiation,
which leads to significant changes in salivary
flow and consistency. The submandibular and
parotid glands are responsible for the produc-
tion of the majority of saliva. Because these
glands are relatively superficial, radiation often
must penetrate through the glands to access the
target tumor. This results in a reduction in
watery saliva as early as the first 1 to 2 weeks of
treatment and an overall estimated prevalence
of xerostomia of 93% during radiation.58 Thus,
SLPs will need to educate patients regarding
strategies to minimize the impact of changes in
salivary flow to facilitate continued oral intake
and exercise performance. Such strategies may
include modification of the diet to include more
soft, moist foods; use of pH balancing mouth
rinses; and avoidance of foods that may cause
increased mucosal irritation. Further exercises
may need to be performed with sips of fluid.
The aforementioned treatment toxicities
may have a negative impact on a patient’s desire
and ability to maintain adequate nutrition and
hydration. Thus, one of the critical decisions that
the SLP may play a role in making is whether or
not a patient requires supplemental nutrition/
hydration via enteral tube feeding. The decision
as to whether to proceed with feeding tube
placement is not an easy decision to make in
most settings. This decision making is further
complicated by limited nonbiased research on
this topic. Thus, the clinician needs to rely on
principles of beneficence and nonmaleficence as
well as the best quality evidence available and
knowledge of the patient’s health status and
functional reserve. Historically, feeding tubes
were placed prophylactically for nutritional pur-
poses; however, studies have demonstrated that
weight loss rates were not necessarily favorable in
patients undergoing prophylactic percutaneous
endoscopic gastrostomy (PEG).59,60 Further,
recent research has demonstrated that patients
with feeding tubes tend to swallow less by mouth
and are at increased risk for dysphagia and
stricture following treatment.61–63 Patients
undergoing prophylactic PEG in particular
have been shown to have higher rates of long-
term PEG dependence.64 Thus, in the prophy-
lactic setting, there is a limited role for prophy-
2019
lactic PEG in patients receiving head and neck
radiation. In selected populations, augmented
nutrition may be necessary. Risk stratification
may be challenging, but there is some limited
evidence regarding which patients are at greatest
risk from a nutritional perspective. One retro-
spective review of patients with oropharyngeal
cancer undergoing chemoradiation found that
patients with body mass index (BMI) <25 at
baseline, T stage of 3 or greater, or cumulative
cisplatin dose of 200 mg/m2 had greater chance
of feeding tube placement during treatment.65
Of those patients receiving a prophylactic tube in
another study, tube use was associated with male
gender, N stage >2, poor baseline performance
status, pretreatment dysphagia, and concurrent
chemotherapy.57 Thus, patients with several of
Downloaded by: Boston University. Copyrighted material.
the aforementioned risk factors may be consi-
dered higher risk for need of enteral feeding.
Reasonable alternatives to prophylactic PEG
include use of a reactive PEG or NG tube.
Patients with reactive NG tubes tend to have
tubes in place for shorter durations and have less
potential for stricture formation.61,66 Severe late
dysphagia rates may be double for patients
receiving PEG rather than NG tube feedings.67
In cases where an NG tube may not be prefer-
able, reactive gastrostomy tubes have been
shown to provide comparable nutritional and
oncologic outcomes to prophylactic PEG with
more favorable functional outcomes.68,69 Thus,
decision making about the need for prophylactic
or reactive tube feedings should take into consi-
deration patient-, tumor-, and treatment-related
factors. It should also be emphasized that the
decision to place a feeding tube does not neces-
sarily equate to the need for NPO status, and
patients with tubes should be encouraged to
continue swallowing at some level to minimize
future dysphagia risk.20,63 NPO status should be
avoided in this population whenever possible
due to the elevated risk of permanent dysphagia.
Patients presenting with dysphagia after
radiation therapy pose a different set of clinical
issues and challenges. The duration of time
elapsed since treatment and the pattern of
dysphagia over the first 2 years following treat-
ment should be considered. Christianen and
colleagues70 evaluated dysphagia patterns after
radiation therapy and stratified patients into five
distinct categories (Table 2). While the proposed
 DECISION MAKING HEAD AND NECK/STARMER, EDWARDS 221

Table 2 Patterns of Postradiation Dysphagia70

Clinical characteristics Potential pathophysiology

Low persistent dysphagia No or minor dysphagia up to 2-y
follow-up
Intermediate persistent Grade 1 dysphagia at 6 mo, relati-
dysphagia vely unchanged to 2-y follow-up
Severe persistent Grade 2 or higher dysphagia at 6
dysphagia mo, relatively unchanged to 2-y fol-
low-up
Transient dysphagia Grade 2 or higher dysphagia at 6 mo
that recovered by 2 y
Progressive dysphagia Less than grade 2 dysphagia at 6
mo, progressing to at least grade 2
during 2-y follow-up
Xerostomia and direct radiation
damage to swallowing structures
Xerostomia and direct radiation
damage to swallowing structures
Xerostomia and direct radiation
damage to swallowing structures
Slow resolution of acute toxicities
such as inflammation and reversible
edema
Progressive fibrosis

Downloaded by: Boston University. Copyrighted material.

pathophysiologies for these categories are not
proven, knowledge of the biological responses to
radiation suggests these different categories
provide an appropriate framework for decision
making regarding intervention strategies.
Patients presenting with low, intermediate,
or severe persistent patterns of dysphagia will
likely benefit from direct interventions targe-
ting the dysphagia characteristics of concern.
This may mean addressing xerostomia, lym-
phedema, or reduced strength and mobility of
the muscles of deglutition. In practice, it would
be challenging to differentiate between those
categories and patients with transient patterns
of dysphagia. Thus, those patients with transi-
ent dysphagia would most likely be treated in a
similar fashion to those patients with persistent
dysphagia, although the duration of treatment
may be abbreviated due to natural recovery.
In contrast, however, patients presenting
with progressive dysphagia may require different
treatment strategies to slow or halt the progres-
sion of fibrosis. Late-onset RAD would fall into
this progressive category, although typically
would present at a later time point (>5 years
postradiation) when fibrosis and cranial neuro-
pathies have advanced. In contrast to other
phenotypes of dysphagia related to radiation,
Awan et al71 defined late RAD as “delayed onset
or progression of pharyngeal dysphagia preceded
by a long interval of adequate functional recovery
from the acute toxicities of radiotherapy.” The
hallmark characteristics of late RAD include
severely inefficient swallowing, not related to
stricture, leading to silent aspiration, primarily of
pharyngeal residue. Unfortunately with late
RAD, traditional therapeutic exercises have
not shown significant benefit due to the severe
and irreversible fibrosis.72 Similarly, neuromus-
cular electrical stimulation does not appear to
provide benefit for this population.73 It appears
that skill-based training (such as McNeill Dysp-
hagia Therapy Program74 and respiratory–swal-
low training75) and compensations76,77 are more
appropriate interventions for patients with late
RAD. “Boot camp” approaches have been sug-
gested for chronic and late RAD patients as well,
with inclusion of intensive skill-based bolus-
driven interventions and airway protective inter-
ventions using EMST leading to encouraging
early results.78,79
In addition to the decision-making chal-
lenges inherent to rehabilitation interventions,
decisions regarding dietary restrictions and
recommendations may be difficult in patients
with postradiation dysphagia, particularly in
patients with chronic or progressive dysphagia
without nutritional or medical complications
related to their dysphagia. In contrast to dysp-
hagia stemming from other etiologies, many
patients with HNC often have a greater degree
of functional reserve and less potential for the
risk factors that have been previously associated
with aspiration pneumonia.80 In a patient who
is maintaining weight and avoiding pulmonary
complications, NPO status and PEG place-
ment should not be the immediate response to
an ineffective swallow. Rather, the clinician
222 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 40, NUMBER 3
should engage in shared decision making with
the patient. This should include evidence-based
information regarding pneumonia risk as well
as strategies that may minimize pneumonia risk
such as compensatory postures/strategies,
immaculate oral hygiene, and maintaining an
active lifestyle. Even in patients who have
experienced medical complications from their
dysphagia, there should be a comprehensive
discussion regarding future risks and patient
goals of care, so that patients may make a
decision that supports their personal goals. It
is important to remember that the majority of
patients with HNC are neurotypical and
capable of making informed decisions regarding
their care. In situations where it is decided to
pursue oral intake despite aspiration, the clini-
cian should carefully document the education
provided and patient/care team conclusions.
Finally, the clinician working with patients
with HNC receiving radiation treatment may
need to make decisions regarding referrals to
other providers. Stricture is a common problem
in patients who have received head and neck
radiation with estimated incidence of 10 to
20%.81–83 Thus, referral to a gastroenterologist
or otolaryngologist may be appropriate for stric-
ture management. As previously mentioned,
lymphedema can impact swallowing function.
Lymphedema management may be provided by
appropriately trained SLPs, occupational thera-
pists, and physical therapists. When edema
appears to be inhibiting ROM of the swallowing
musculature, referral for treatment should be
pursued. Patients will often encounter issues
with nutrition as a result of their treatment
and/or dysphagia. The SLP may be an important
advocate for ensuring appropriate follow-up
with a registered dietician.
NONSURGICAL CASE STUDY
The following case study exemplifies some of the
challenges that may be encountered when wor-
king with nonsurgical HNC patients. JL was a
56-year-old male diagnosed with a HPV-asso-
ciated squamous cell carcinoma of the right
tongue base (T2N2b). His treatment team
recommended primary chemoradiation. At the
time of diagnosis, he was not aware of any
changes in his swallowing. Despite this, given
2019
the evidence of potential for subclinical dyspha-
gia, his radiation oncologist referred him for a
formal swallowing evaluation and preradiation
intervention. A FEES examination revealed mild
pharyngeal residue but no laryngeal penetration
or aspiration. The patient was on an unrestricted
diet with stable weight and a BMI of 30. The
SLP recommended the patient not to receive a
prophylactic feeding tube given that he did not
exhibit significant risk factors for needing a tube.
The patient was provided with prophylactic
swallowing exercises, which he completed incon-
sistently throughout the treatment. He required
extensive counseling by the SLP to maintain oral
intake due to loss of appetite due to taste changes.
Though he lost some weight during treatment,
Downloaded by: Boston University. Copyrighted material.
this was less than 5% of his ideal body weight;
therefore, the SLP, dietician, and oncology team
concurred that a feeding tube was not necessary
for his nutrition. His posttreatment videofluo-
roscopic swallowing assessment revealed mild
pharyngeal dysphagia related to reduced pharyn-
geal propulsion from restricted pharyngeal const-
riction and tongue base retraction. Epiglottic tilt
was diminished, but no laryngeal penetration or
aspiration was noted. His Dynamic Imaging
Grade of Swallowing Toxicity (DIGEST) sco-
res84 were as follows: safety ¼ 0, efficiency ¼ 1,
overall severity grade ¼ 1. He was encouraged to
continue his maintenance exercises and to return
to a normal diet as tolerated.
One year following radiation, his swallow
was minimally impaired and marked only by
mild reduction in pharyngeal constriction and
sluggish epiglottic tilt without penetration or
aspiration. Six years after completion of radia-
tion, the patient contacted his radiation oncolo-
gist with complaints of increased difficulty
swallowing and speaking. Despite his perceived
difficulty, his weight was stable and he had not
experienced pneumonias. He was referred for a
videofluoroscopic swallowing study. Oral motor
evaluation revealed right hemi-tongue atrophy
with fasciculations. His swallow study revealed
moderate-severe deficits with severely reduced
pharyngeal propulsion with retention of appro-
ximately 50% of each bolus after the swallow. He
had persistent deep penetration to the vocal folds
with liquids after the swallow due to overflow of
residue but no aspiration. His DIGEST scores
were as follows: safety grade ¼ 2, efficiency
 DECISION MAKING HEAD AND NECK/STARMER, EDWARDS
grade ¼ 3, overall severity grade ¼ 3. There
was no evidence of stricture to account for the
noted residue.
The SLP had a candid conversation with the
patient regarding the nature of the dysphagia and
the prognosis for late RAD. They identified
compensatory strategies such as a head tilt to
the left and multiple effortful swallows which
minimized the residue and therefore the penet-
ration. Because the patient was maintaining his
weight and avoiding pulmonary complications, a
feeding tube was not recommended; however,
the patient was counseled that progression of the
dysphagia could lead to adverse consequences.
The patient was enrolled in a course of therapy
focusing primarily on respiratory swallowing
coordination therapy and EMST use to mini-
mize aspiration risk and complications. Respira-
tory swallowing coordination therapy utilized
biofeedback pairing submental EMG and nasal
airflow to allow the patient to visualize where in
the respiratory cycle he was swallowing and thus
improved his ability to adjust his abnormal
respiratory-swallowing pattern. Oral care was
emphasized to minimize the risk of aspiration
of colonized oral secretions and the patient was
advised to notify the care team should any signs
of weight loss or pulmonary infection arise.
Within 18 months, the patient had worsening
of his dysphagia and a new-onset right vocal fold
paralysis. He developed aspiration pneumonia
but was maintaining his weight. The patient
indicated understanding the risks of additional
pneumonias but indicated he did not want to
alter his diet or consider a feeding tube. The SLP
counseled the patient further and documented
his wishes in the medical record. He was referred
to a laryngologist for consideration of vocal fold
injection to improve glottic closure and cough
efficiency. This paired with additional respiratory
swallowing therapy eliminated aspiration and no
further incidents of pneumonia were noted.
CONCLUSIONS
Management of dysphagia associated with HNC
is challenging and frequently requires complex,
multidisciplinary decision making. Decisions
may include whether baseline function is incon-
gruent with proposed oncologic treatment (such
as an organ preservation approach when the
223
larynx is dysfunctional at baseline), what diet
level is safe and appropriate, whether tube fee-
ding is necessary, how to maintain and restore
function, and when to focus rehabilitative efforts
on compensation. Risk-guided decision making
is critical in this population, as many patients are
at a lower risk for complications from dysphagia
due to fewer medical comorbidities and neuro-
typical baseline status. Thus, SLPs providing
care to this population should have a compre-
hensive understanding of the different phenoty-
pes of dysphagia in HNC, factors associated with
elevated risk of developing complications, and
patient goals of care. At all stages of decision
making, patient autonomy and preference should
be emphasized. When thoughtful decision
Downloaded by: Boston University. Copyrighted material.
making is applied in the management of dysp-
hagia associated with HNC, patient function and
outcomes may be optimized.
DISCLOSURES
Neither author has any financial or nonfinancial
disclosures.
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