What is the condition?
Dysphagia refers to difficulty swallowing. Dysphagia is common in head and neck cancer patients and survivors.
What causes difficulty swallowing?
Dysphagia may be caused by several different things. Tumors may prevent food or liquid from passing from the mouth and throat into the esophagus, or it may invade anatomic structures causing decreased function. Surgery that removes tumors may also remove or damage tissues that are important for swallow function. Radiation or the combination of radiation and chemotherapy can cause significant mouth sores during therapy causing painful swallowing (odynophagia). Surgery or radiation may cause swelling (edema or lymphedema) or scaring (fibrosis) of the lining of the mouth and throat causing decrease swallowing function. Scaring may become severe enough that a stricture develops (narrowing of the esophagus that blocks the passage of food to the stomach).
Other common problems in head and neck cancer patients that may also cause swallowing problems include: dry mouth from radiation making food sticky, loss of teeth or poorly fitting dentures causing chewing problems, taste changes causing gagging on food or liquids, and a loss or change of sensation which alters the way a patient eats.
When does difficulty swallowing develop?
Dysphagia occurs in most patients to some extent. For some patients swallowing difficulty is the first indications of a tumor. In patients who undergo surgery, swallowing issues may be present immediately after surgery. For many patients, swallowing will improve in a few weeks after surgery. If the surgery is extensive, swallowing may be affected permanently.
During chemotherapy and radiation therapy inflammation and sores in the lining the mouth and throat (mucositis) develops. Mucositis causes pain and swelling which may result in difficulty or painful swallowing (dysphagia/odynophagia). Generally, this improves within 2 to 3 months after the treatment is completed.
Long term, most patients do very well and resume a normal or near normal diet, however, some may experience swallowing issues that impact on the types of foods that can be eaten. A small percentage of patients have severe swallowing issues that necessitate the use of a permanent feeding tube. Scar tissue formation can affect swallowing function months to years after treatment is completed. Each patient is different and therefore diagnosis and therapy are determined on an individual basis.
What is the impact of dysphagia on my health?
Maintaining balanced nutrition and proper hydration is a top priority during and after cancer treatment in order to promote proper healing and recovery with minimal complications. Patients who have difficulty swallowing will often lose weight. If patients cannot maintain weight with nutrition by mouth, a feeding tube may be needed.
During normal swallowing, structures in the throat direct food into the long tube (the esophagus) that connects the mouth with the stomach. These structures also prevent food from entering the lungs. When these structures are damaged food particles or drops of liquid fall into the windpipe and lungs. This is called aspiration. Aspiration may cause a pneumonia or obstruction of the airways.
What are the signs/symptoms of dysphagia?
Signs or symptoms of dysphagia are highly variable. A patient can experience:
- Coughing or choking when eating or drinking
- Sensation of food getting stuck
- Food or liquid passing into or out of the nose with swallowing
- Decreased ability to chew or swallow solids
- Unintended weight loss
- Increased time required to eat a meal
- Effortful swallowing
- Difficulty swallowing pills or tablets
- Recurring pneumonias
How is it diagnosed?
The presence of dysphagia can often be established with history alone. To fully test swallowing function, additional tests may be ordered.
- Barium Esophagram: This is an x-ray procedure that can be used to diagnose simple narrowing of the swallow tube or leaking after reconstruction of the pharynx. A radiologist conducts this exam.
- Modified Barium Swallow: This is a procedure where the radiologist and speech pathologist assess your ability to swallow different food consistencies (thin liquids, thickened liquids, and solids) using motion radiographs. If you are found to have a swallowing abnormality, the speech pathologist will try to determine if there are ways to compensate for the functional loss (compensatory swallowing maneuvers). These maneuvers may improve your ability to swallow and prevent or reduce aspiration events.
- Fiberoptic Endoscopic Evaluation of Swallowing (FEES): This is an office procedure which provides a direct visualization of swallowing function using a flexibly scope through the nose. It enables the clinician to directly identify where the food is going and where passage is difficult, while avoiding radiation exposure. This can also be used as a tool for providing interactive feedback to the patient regarding their ability or inability to swallow food and liquid.
Can dysphagia be prevented?
For patients treated with radiation or a combination of chemotherapy and radiation therapy, studies have shown that continuing to use the muscles and to stimulate the tissues of the throat during treatment results in improved swallowing function. It is critical that you continue to eat and drink to the extent that you are able throughout the duration of cancer therapy. Doing so will keep the muscle strong and the tissues healthier. Your treatment team, which typically includes a dietician and speech pathologist will assist you in determining which foods will be easiest to swallow. If they feel that swallow function is poor they may recommend the use of a feeding tube in order to get enough calories. Even if a feeding tube is required, continuing to swallow and performing swallowing exercises is of the utmost importance.
How dysphagia is treated?
If you develop dysphagia you will see a speech pathologist. These are individuals who are trained to test swallowing function, provide recommendations on a safe diet, and perform swallow therapy. Dysphagia therapy may involve a specific exercise program to regain strength and range of motion of swallowing structures, or training in the use of compensatory maneuvers to improve swallowing efficiency and prevent aspiration. Therapy may be short-term or require several months. Success is possible, and fortunately most patients are able to resume eating by mouth, though slight diet modifications may be required. Physical therapy and passive motion devices may help to alleviate a reduction in jaw opening (trismus) that is the result of radiation treatments. If a stricture develops, esophagoscopy and dilation in the operating room may provide significant improvement.
When should I call my doctor?
Things that should lead you to call your doctor include:
- Inability to eat things that you used to enjoy
- Persistent coughing or choking on food
- Recurrent pneumonias
- New pain with eating
- Unexplained weight loss
- Unexplained change in the food consistencies that you can eat
- Decreased pleasure in eating