It’s common for patients to experience difficulty swallowing if they have a neurological disorder, had a stroke or cancer of the head or neck.
During or after treatment, up to 70% of patients with head and neck cancers experience dysphagia. Cancer and radiation can damage one or more of the many muscles or nerves needed to swallow. But now, clinicians are seeing other growing populations of dysphagia, including those who have oropharyngeal cancer associated with human papillomavirus (HPV).
Dysphagia can not only keep patients from eating and drinking, it can be life-threatening. Nearly one third of head and neck cancer patients develop aspiration pneumonia after treatment. About 30% of those patients die within the first year of developing the condition.
And yet, for decades, few options were available to restore or even improve patients’ swallowing.
Clinic focused on dysphagia
In 2021, The Ohio State University Wexner Medical Center opened the first-of-its-kind clinic focused on treating patients with head and neck cancer who develop dysphagia. Led by a laryngologist and staffed by a multidisciplinary team of specialists, the clinic provides comprehensive testing, treatment and preventive care, all guided by innovative research.
Through the clinic’s efforts, more and more patients have improved their swallowing and speaking ability through exercises, medication, surgery or other procedures.
“A lot of people feel better. They aspirate less often. Their quality of life is improved,” says Apoorva Ramaswamy, MD, a laryngologist and surgeon at The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute (OSUCCC – James). She’s also an assistant clinical professor in the Department of Otolaryngology – Head and Neck Surgery at The Ohio State University College of Medicine.
An interdisciplinary team of dysphagia specialists at the Ohio State Wexner Medical Center treats patients and pursues research to enhance quality of life for people living with the condition. That team includes speech and language pathologists, dietitians, physical therapists and social workers.
Predictive model for dysphagia risk
Another key leader on the dysphagia treatment team is internationally recognized researcher and dysphagia expert Emily Plowman, PhD, CCC-SLP, a professor of Otolaryngology – Head and Neck Surgery at the Ohio State College of Medicine. Dr. Plowman directs the Aerodigestive Research Core laboratory, which improves assessment and clinical management of dysphagia, and runs a clinic treating and preventing dysphagia.
Dr. Plowman’s research on a cardiac intensive care unit led her to develop an algorithm model that predicts a patient’s risk for developing dysphagia after surgery.
During surgery, intubation can damage some of the structures involved in swallowing. Also, during heart surgeries, trauma can occur to the recurrent laryngeal nerve, which wraps around the aortic arch and controls muscles involved in voice and swallowing.
As a result, some patients experience silent aspiration following surgery. Food or liquids end up in their airway and don’t trigger a cough response.
“Dysphagia has gone undetected previously in most settings,” Dr. Plowman says. “That has led to negative patient outcomes that could otherwise be prevented. The goal of our newly developed prediction tool is to identify patients at the highest risk of developing dysphagia to support personalized triage care pathways.”
The model Dr. Plowman and her colleagues created forecasts a patient’s level of dysphagia risk based on:
- Age
- Medical history
- Surgery type
- Size of the endotracheal tube
- Duration of intubation
- Number of surgeries the patient has had
If a patient is found to be at high risk of aspirating following surgery, adjustments can be made in conducting the surgery to significantly lower that risk.
Dysphagia bedside screening tool
Along with predicting dysphagia risk, Dr. Plowman and her colleagues are validating a novel screening tool for nurses to use in the ICU bedside post-surgery to detect if a patient has developed dysphagia.
“By accurately identifying dysphagia in this patient population, we have the potential to reduce the development of pneumonia, reintubation and possibly death. All of these are associated with dysphagia in the cardiac ICU,” says Dr. Plowman, who was just named president of the international Dysphagia Research Society.
Pioneering new treatments for dysphagia
At Ohio State’s dysphagia clinic, a wide array of treatment options is now available for patients:
- Prolotherapy: If patients have difficulty opening their mouth because of radiation scarring, dextrose injections in the jaw encourage tissue repair, helping patients open their jaw wider to chew better.
- Dilation of the pharyngoesophageal segment: Radiation and surgical scarring can lead to narrowing at the pharyngoesophageal segment, particularly in head and neck cancer survivors. At Ohio State, clinicians use a specialized approach to dilate this area, improving passage of food and liquid without the need for traditional esophageal dilation.
- Respiratory muscle strength training: A resistance breathing exercise is used to strengthen the muscles involved in airway clearance and protect and defend the airway, to improve swallowing and coughing ability.
- Lip augmentation surgery: Nerve damage in the lips can limit the ability to properly contain food and liquids. Augmentation surgery can help reshape lips to resolve the problem.
- Palate surgery: Surgery on the palate strengthens the seal between the mouth and nasal passage to prevent food or liquids from entering the nasal cavity.
Rise in HPV cases leading to more dysphagia
While dysphagia is most common in older individuals, more people 45 to 65 years old are experiencing it. That’s as a result of the rising incidence of oropharyngeal cancer in this population due to HPV, says Matthew Old, MD, director of the Head and Neck Cancer Program at the OSUCCC – James.
“We’re treating younger patients with head and neck cancer who will live longer and suffer the consequences of treatment, including dysphagia,” says Dr. Old, who’s also a professor at the College of Medicine. “We have a growing population of dysphagia patients who are living longer so it’s imperative we focus our efforts on improving their quality of life.”
While it may not always be possible to fully restore a patient’s ability to swallow, improvements can often be made so a patient no longer requires a feeding tube, needs it less frequently or can finally eat solid foods after months of having only liquids.
“If you have patients who are having quality of life issues from stroke, head and neck cancer or neurodegenerative diseases, there’s a lot we can do for them,” Dr. Ramaswamy says.
“So much has changed in the last 10 years. The tools we have at our disposal have really evolved. There’s hope for these patients.”