L. van der Molen

Evaluation of long term (10-years+) dysphagia and trismus in patients treated with concurrent chemo-radiotherapy for advanced head and neck cancer.

OBJECTIVES Assessment of long term (10-years+) swallowing function, mouth opening, and quality of life (QoL) in head and neck cancer (HNC) patients treated with chemo-radiotherapy (CRT) for advanced stage IV disease. MATERIALS AND METHODS Twenty-two disease-free survivors, participating in a multicenter randomized clinical trial for inoperable HNC (1999-2004), were evaluated to assess long-term morbidity. The prospective assessment protocol consisted of videofluoroscopy (VFS) for obtaining Penetration Aspiration Scale (PAS) and presence of residue scores, Functional Oral Intake Scale (FOIS) scores, maximum mouth opening measurements, and (SWAL-QOL and study-specific) questionnaires. RESULTS At a median follow-up of 11-years, 22 patients were evaluable for analysis. Ten patients (46%) were able to consume a normal oral diet without restrictions (FOIS score 7), whereas 12 patients (54%) had moderate to serious swallowing issues, of whom 3 (14%) were feeding tube dependent. VFS evaluation showed 15/22 patients (68%) with penetration and/or aspiration (PAS⩾3). Fifty-five percent of patients (12/22) had developed trismus (mouth opening⩽35mm), which was significantly associated with aspiration (p=.011). Subjective swallowing function (SWAL-QOL score) was impaired across almost all QoL domains in the majority of patients. Patients treated with IMRT showed significantly less aspiration (p=.011), less trismus (p=.035), and less subjective swallowing problems than those treated with conventional radiotherapy. CONCLUSION Functional swallowing and mouth opening problems are substantial in this patient cohort more than 10-years after organ-preservation CRT. Patients treated with IMRT had less impairment than those treated with conventional radiotherapy.

Current assessment and treatment strategies of dysphagia in head and neck cancer patients: a systematic review of the 2012/13 literature.

Purpose of reviewDysphagia, or swallowing impairment, is a serious sequel of head and neck cancer (HNC) and its treatment. This review focuses on the rapidly growing literature published during the past 2 years about the current assessment and treatment strategies of dysphagia in HNC patients. Recent findingsFunctional swallowing assessment has become standard of care in many HNC centers, to prevent or identify (silent) aspiration, to optimize functional outcomes, and to determine the appropriate rehabilitation strategy. Also preventive swallowing exercises are considered more and more in the pretreatment setting with promising results on (pharyngeal) swallowing function. However, there is a lack of consensus regarding type, frequency, or intensity of the exercises. Furthermore, long-term follow-up of swallowing function might be necessary, given the potential for long-term sequels following HNC treatment. SummaryRegarding dysphagia evaluation, there is still a lack of a uniform ‘gold-standard’ for both assessment and treatment strategies. More high-quality data, adequately controlled, adequately powered and randomized, on prophylactic and therapeutic swallowing exercises are needed, with longer follow-up and better adherence to treatment, for better understanding the effects of chemo and radiotherapy dosage, and of frequency, timing and duration of treatment, to improve swallowing function and optimize quality of life.

Practice of laryngectomy rehabilitation interventions: a perspective from Europe/the Netherlands.

Purpose of reviewTotal laryngectomy rehabilitation (TLR) in Europe is not uniform, with quite some differences in approach and infrastructure between various countries. In, for example, the Netherlands, Switzerland, Scandinavia, and more recently also in the UK, head and neck cancer (HNC) treatment and rehabilitation shows a high level of centralization in dedicated HNC centres. In other European countries, the level of centralization is lower, with more patients treated in low-volume hospitals. This article focusses on the situation in the Netherlands and, where applicable, will discuss the regional variations in Europe. Recent findingsProsthetic surgical voice restoration (PSVR) presently is the method of choice in Europe, and use of oesophageal and electrolarynx voice has moved to the background. In most European countries (except the UK and Ireland), PSVR is physician driven, with an indispensable role for speech–language pathologists and increasingly for oncology nurses. Indwelling voice prostheses are mostly preferred, also because these devices can be implanted at the time of trachea–oesophageal puncture. Pulmonary rehabilitation is achieved with heat and moisture exchangers, which, based on extensive clinical and basic physiology research, are considered an obligatory therapy measure. In addition to PSVR, also issues such as smoking cessation, dysphagia/swallowing rehabilitation, and olfaction/taste rehabilitation are discussed. Especially, the latter has shown great progress over the last decade and is another example of increasing implementation of evidence-based practice in TLR. SummaryTLR has shown considerable progress over the last decades, and through the intensified collaboration between all clinicians involved, significantly has improved vocal, pulmonary, and olfactory rehabilitation after total laryngectomy.

PO-0635: Dose to the masseter muscle and risk of trismus after chemoradiation for advanced head & neck cancer

Purpose / objective: Head and neck cancer patients treated with chemoradiation are at risk for developing trismus (reduced mouth opening). Trismus is often a persisting side-effect and difficult to manage. It impairs eating, speech and oral hygiene, affecting quality of life. Although several studies identified the masseter muscle (MM) as one of the main organs at risk, currently this structure is rarely considered during treatment planning. Prospective studies for chemoradiation are lacking. The aim of our study was to quantify the relationship between radiation dose to the MM and development of radiation-induced trismus in an IMRT-VMAT population. Results: At the first evaluation, 6-12 weeks post-treatment, fourteen patients had developed radiation-induced trismus (15%). On average, mouth opening decreased with 4.1 mm, or 8.2 % relative to baseline. Mean dose to the ipsilateral MM was a stronger predictor for trismus than mean dose to the contralateral MM, as indicated by the lowest -2 log likelihood (Table 1). Figure 1A shows the correlation between the ipsilateral mean masseter dose and the relative decrease in mouth opening, with trismus cases indicated in red. No trismus cases were observed in 33 patients (35%) with a mean dose to the ipsilateral MM 50 Gy. Patients with tumors located in the oropharynx were at highest risk.