Radiation-associated Dysphagia Research Articles

Self-management intervention improves patient adherence to swallowing exercises during radiation for head and neck cancer.

While preventive swallowing exercises reduce the risk of radiation-associated dysphagia in patients with head and neck cancer, strategies are needed to improve patient adherence. Before radiation, all participants were taught preventive swallowing exercises and randomized to either an adherence intervention or enhanced usual care. During radiation, all participants met twice with a speech pathologist for swallowing assessment and reinforcement of exercises. Intervention participants met weekly with a counselor in-person or by phone. At 6-week post-radiation follow-up, all participants completed a follow-up assessment of self-reported adherence, which was then corroborated with medical record documentation. Newly diagnosed pharyngeal and laryngeal cancer patients without distant metastases were randomized (n = 265; 135 to intervention, and 130 to usual care). Intervention participants were more likely to adhere to exercises during radiation compared to the control group (p < 0.0001). The weekly in-person adherence intervention program significantly increased patient's adherence to preventive swallowing exercises during radiation.

Swallowing-related muscle inflammation and fibrosis induced by a single dose of radiation exposure in mice

BackgroundAlthough radiotherapy is commonly used to treat head and neck cancer, it may lead to radiation-associated dysphagia (RAD). There are various causes of RAD, however, the mechanism has not yet been fully identified. Currently, the only effective treatment for RAD is rehabilitation. Additionally, there are few available animal models of RAD, necessitating the development of new models to establish and evaluate RAD treatments. We hypothesize that radiation-induced neck muscle fibrosis could be one of the causes of RAD due to impairment of laryngeal elevation. Therefore, in this study, we focused on the changes in inflammation and fibrosis of the strap muscles (Sternohyoid, Sternothyroid, and Thyrohyoid muscles) after a single-dose irradiation. This research aims to provide a reference animal model for future studies on RAD.ResultsCompared to control mice, those treated with 72-Gy, but not 24-Gy, irradiation had significantly increased tumor necrosis factor-α (TNF-α) (p < 0.01) and α-smooth muscle actin (αSMA) (p < 0.05) expression at 10 days and significantly increased expression levels of motif chemokine ligand-2 (CCL2), α-SMA, tumor growth factor-β1 (TGF-β1), type1 collagen, and interleukin-1β (IL-1β) (p < 0.05) in the muscles at 1 month by real-time PCR analysis. The results of immunohistochemistry showed that the deposition of type 1 collagen gradually increased in extracellular space after radiation exposure, and the positive area was significantly increased at 3 months compared to non-irradiated control.ConclusionsA single dose of 72-Gy irradiation induced significant inflammation and fibrosis in the strap muscles of mice at 1 month, with immunohistochemical changes becoming evident at 3 months. This cervical irradiation-induced fibrosis model holds potential for establishing an animal model for RAD in future studies.Level of evidenceN/A.

62 What is the functional gain?

Swallow optimized IMRT is now supported by level 1 evidence from the phase III DARS trial (CRUK/14/014). By avoiding non-target RT dose to the pharyngeal constrictors, dysphagia optimized IMRT achieved mean MDADI score 7.2 points lower than conventional IMRT as 12 months. What does this mean? Is this a meaningful difference in swallowing function? Will the functional gain be durable into the second decade of survivorship?After a primer on radiation-associated dysphagia in oropharyngeal cancer, the presenter will pragmatically interpret the DARS results from the perspective of a dysphagia specialist - including implications for supportive care. DARS results will be put into context of contemporary function-sparing trials in oropharynx cancer.

Iterative Patient Testing of a Stimuli-Responsive Swallowing Activity Sensor to Promote Extended User Engagement During the First Year After Radiation: Multiphase Remote and In-Person Observational Cohort Study.

Frequent sensor-assisted monitoring of changes in swallowing function may help improve detection of radiation-associated dysphagia before it becomes permanent. While our group has prototyped an epidermal strain/surface electromyography sensor that can detect minute changes in swallowing muscle movement, it is unknown whether patients with head and neck cancer would be willing to wear such a device at home after radiation for several months. We iteratively assessed patients' design preferences and perceived barriers to long-term use of the prototype sensor. In study 1 (questionnaire only), survivors of pharyngeal cancer who were 3-5 years post treatment and part of a larger prospective study were asked their design preferences for a hypothetical throat sensor and rated their willingness to use the sensor at home during the first year after radiation. In studies 2 and 3 (iterative user testing), patients with and survivors of head and neck cancer attending visits at MD Anderson's Head and Neck Cancer Center were recruited for two rounds of on-throat testing with prototype sensors while completing a series of swallowing tasks. Afterward, participants were asked about their willingness to use the sensor during the first year post radiation. In study 2, patients also rated the sensor's ease of use and comfort, whereas in study 3, preferences were elicited regarding haptic feedback. The majority of respondents in study 1 (116/138, 84%) were willing to wear the sensor 9 months after radiation, and participant willingness rates were similar in studies 2 (10/14, 71.4%) and 3 (12/14, 85.7%). The most prevalent reasons for participants' unwillingness to wear the sensor were 9 months being excessive, unwanted increase in responsibility, and feeling self-conscious. Across all three studies, the sensor's ability to detect developing dysphagia increased willingness the most compared to its appearance and ability to increase adherence to preventive speech pathology exercises. Direct haptic signaling was also rated highly, especially to indicate correct sensor placement and swallowing exercise performance. Patients and survivors were receptive to the idea of wearing a personalized risk sensor for an extended period during the first year after radiation, although this may have been limited to well-educated non-Hispanic participants. A significant minority of patients expressed concern with various aspects of the sensor's burden and its appearance. ClinicalTrials.gov NCT03010150; https://clinicaltrials.gov/study/NCT03010150.

Assessment of radio(chemo)therapy-related dysphagia in head and neck cancer patients based on cough-related acoustic features: a prospective phase II national clinical trial (ACCOUGH-P/A trial)

BackgroundRadiation-associated dysphagia is defined as impaired swallowing efficiency/safety following (chemo)radiotherapy in head and neck cancer patients. In a dysphagia framework, impaired coughing may lead to lung aspiration and fatal lung infection. Although cough efficacy is a predictor of the risk of aspiration, cough investigation is minimal in patients with radiation-associated dysphagia. Because cough is a transient signal, existing software for speech analysis are not appropriate. The goal of our project is to develop an assessment method using acoustic features related to voluntary and reflexive coughs as biomarkers of the risk of penetration/aspiration in patients with radiation-associated dysphagia.MethodsHealthy subjects and head and neck cancer patients with and without dysphagia will produce voluntary coughs, throat clearings and reflexive coughs. Recordings will be made using an acoustic microphone and a throat microphone. The recorded signals will be manually segmented and subsequently analysed with a software under development. Automatic final segmentation enables to measure cough duration. The first method of analysis includes temporal features: the amplitude contour, the sample entropy and the kurtosis. These features report respectively the strength, the unpredictability (turbulence noise due to the air jet) and the impulsive quality (burst) of the signal. The second method of analysis consists of a spectral decomposition of the relative cough signal energy into several frequency bands (0–400 Hz, 400–800 Hz, 800–1600 Hz, 1600–3200 Hz, > 3200 Hz). The primary outcome of this exploratory research project is the identification of a set of descriptive acoustic cough features in healthy subjects as reference data (ACCOUGH). The secondary outcome of this research in head and neck cancer patients with radiation-associated dysphagia includes the identification of (1) a set of descriptive acoustic cough features as biomarkers of penetration-aspiration (ACCOUGH-P/A), (2) swallowing scores, (3) voice features and (4) aerodynamic cough features.DiscussionThis study is expected to develop methods of acoustic cough analysis to enhance the assessment of radiation-associated dysphagia in head and neck cancer patients following (chemo)radiation.Trial registrationInternational Standard Randomized Controlled Trials Number (ISRCTN) registry ISRCTN16540497. Accepted on 23 June 2023.

Spatially-aware clustering improves AJCC-8 risk stratification performance in oropharyngeal carcinomas

ObjectiveEvaluate the effectiveness of machine learning tools that incorporate spatial information such as disease location and lymph node metastatic patterns-of-spread, for prediction of survival and toxicity in HPV+ oropharyngeal cancer (OPC). Materials & methods675 HPV+ OPC patients that were treated at MD Anderson Cancer Center between 2005 and 2013 with curative intent IMRT were retrospectively collected under IRB approval. Risk stratifications incorporating patient radiometric data and lymph node metastasis patterns via an anatomically-adjacent representation with hierarchical clustering were identified. These clusterings were combined into a 3-level patient stratification and included along with other known clinical features in a Cox model for predicting survival outcomes, and logistic regression for toxicity, using independent subsets for training and validation. ResultsFour groups were identified and combined into a 3-level stratification. The inclusion of patient stratifications in predictive models for 5-yr Overall survival (OS), 5-year recurrence free survival, (RFS) and Radiation-associated dysphagia (RAD) consistently improved model performance measured using the area under the curve (AUC). Test set AUC improvements over models with clinical covariates, was 9 % for predicting OS, and 18 % for predicting RFS, and 7 % for predicting RAD. For models with both clinical and AJCC covariates, AUC improvement was 7 %, 9 %, and 2 % for OS, RFS, and RAD, respectively. ConclusionIncluding data-driven patient stratifications considerably improve prognosis for survival and toxicity outcomes over the performance achieved by clinical staging and clinical covariates alone. These stratifications generalize well to across cohorts, and sufficient information for reproducing these clusters is included.

Acoustic Analysis of Voluntary Coughs, Throat Clearings, and Induced Reflexive Coughs in a Healthy Population.

Cough efficacy is considered a reliable predictor of the aspiration risk in head and neck cancer patients with radiation-associated dysphagia. Currently, coughing is assessed perceptually or aerodynamically. The goal of our research is to develop methods of acoustic cough analysis. In this study, we examined in a healthy population the acoustical differences between three protective maneuvers: voluntary cough, voluntary throat clearing, and induced reflexive cough. Forty healthy participants were included in this study. Voluntary cough, voluntary throat clearing, and reflexive cough samples were recorded and analyzed acoustically.Temporal acoustic features were the following: the slope and curvature of the amplitude contour, as well as the average, slope, and curvature of the sample entropy and kurtosis contours of the recorded signal. Spectral features were the relative energy in the frequency bands (0-400Hz, 400-800Hz, 800-1600Hz, 1600Hz-3200Hz, > 3200Hz) as well as the weighted spectral energy. Results showed that, compared to a voluntary cough, a throat clearing starts with a weaker onset pulse and involves oscillations from the onset to the offset (concave curvature of the amplitude contour, p < 0.05), lower average (p < 0.05), and slope (p < 0.05) as well as lower convex curvature (p < 0.05) of the kurtosis contour. An induced reflexive cough starts with a higher and briefer onset burst and includes higher frication noise (larger convexity of the curvature of the amplitude and kurtosis contours (p < 0.05)) compared to a voluntary cough. The conclusion is that voluntary coughs are acoustically significantly different from voluntary throat clearings and induced reflexive coughs.

Home-based intensive treatment of chronic radiation-associated dysphagia in head and neck cancer survivors (HIT-CRAD trial)

BackgroundChronic radiation-associated dysphagia (C-RAD) is considered to be one of the most severe functional impairments in head and neck cancer survivors treated with radiation (RT) or chemoradiation (CRT). Given the major impact of these late toxicities on patients’ health and quality of life, there is a strong need for evidence-based dysphagia management. Although studies report the benefit of strengthening exercises, transference of changes in muscle strength to changes in swallowing function often remains limited. Therefore, combining isolated strengthening exercises with functional training in patients with C-RAD may lead to greater functional gains.MethodsThis 3-arm multicenter randomized trial aims to compare the efficacy and possible detraining effects of mere strengthening exercises (group 1) with a combination of strengthening exercises and functional swallowing therapy (group 2) and non-invasive brain stimulation added to that combination (group 3) in 105 patients with C-RAD. Patients will be evaluated before and during therapy and 4 weeks after the last therapy session by means of swallowing-related and strength measures and quality of life questionnaires.DiscussionOverall, this innovative RCT is expected to provide new insights into the rehabilitation of C-RAD to optimize post-treatment swallowing function.Trial registrationInternational Standard Randomized Controlled Trials Number (ISRCTN) registry ID ISRCTN57028065. Registration was accepted on 15 July 2021.

Precision association of lymphatic disease spread with radiation-associated toxicity in oropharyngeal squamous carcinomas

PurposeTo determine whether patient similarity in terms of head and neck cancer spread through lymph nodes correlates significantly with radiation-associated toxicity. Materials and methods582 head and neck cancer patients received radiotherapy for oropharyngeal cancer (OPC) and had non-metastatic affected lymph nodes in the head and neck. Affected lymph nodes were segmented from pretreatment contrast-enhanced tomography scans and categorized according to consensus guidelines. Similar patients were clustered into 4 groups according to a graph-based representation of disease spread through affected lymph nodes. Correlation between dysphagia-associated symptoms and patient groups was calculated. ResultsOut of 582 patients, 26% (152) experienced toxicity during a follow up evaluation 6 months after completion of radiotherapy treatment. Patient groups identified by our approach were significantly correlated with dysphagia, feeding tube, and aspiration toxicity (p < .0005). DiscussionOur results suggest that structural geometry-aware characterization of affected lymph nodes can be used to better predict radiation-associated dysphagia at time of diagnosis, and better inform treatment guidelines. ConclusionOur work successfully stratified a patient cohort into similar groups using a structural geometry, graph-encoding of affected lymph nodes in oropharyngeal cancer patients, that were predictive of late radiation-associated dysphagia and toxicity.

Inter-Observer Variation in Delineating the Pharyngeal Constrictor Muscle as Organ at Risk in Radiotherapy for Head and Neck Cancer.

Background and PurposeTo evaluate the inter-observer variation (IOV) in pharyngeal constrictor muscle (PCM) contouring, and resultant impact on dosimetry and estimated toxicity, as part of the pre-trial radiotherapy trial quality assurance (RTQA) within DARS, a multicenter phase III randomized controlled trial investigating the functional benefits of dysphagia-optimized intensity-modulated radiotherapy (Do-IMRT) in pharyngeal cancers.Methods and MaterialsOutlining accuracy of 15 clinicians’ superior and middle PCM (SMPCM) and inferior PCM (IPCM) were retrospectively assessed against gold standards (GS) using volume, location, and conformity indices (CIs) on a pre-trial benchmark case of oropharyngeal cancer. The influence of delineation variability on dose delivered to the constrictor muscles with Do-IMRT and resultant normal tissue complication probability (NTCP) for physician-scored radiation-associated dysphagia at 6 months was evaluated.ResultsFor GS, SMPCM, and IPCM volumes were 13.51 and 1.67 cm3; corresponding clinician mean volumes were 12.18 cm3 (SD 3.0) and 2.40 cm3 (SD 0.9) respectively. High IOV in SMPCM and IPCM delineation was observed by the low DICE similarity coefficient value, along with high geographical miss index and discordance index values. Delineation variability did not significantly affect the mean dose delivered to the constrictors, relative to the GS plan. Mean clinician NTCP was 24.6% (SD 0.6), compared to the GS-NTCP of 24.7%.ConclusionsResults from this benchmark case demonstrate that inaccurate PCM delineation existed, even with protocol guidelines. This did not impact on delivered dose to this structure with Do-IMRT, or on estimated swallowing toxicity, in this single benchmark case.

Quality of Survival of Head and Neck Cancer Patients

The ultimate purpose of cancer treatment is to improve the quality of life (QOL) of the patient besides prolonging the survival. As the prognosis of patients with head and neck cancers improves, attention has been directed at the QOL of the cancer survivors, that is, the quality of survival (QOS). The concept of cancer survivorship refers to the patient showing no signs of cancer after treatment completion, that is, living with, through, and beyond cancer with the family, caregivers, and other survivors. In this editorial, the authors describe the current status and future perspectives, including efforts at our hospital for evaluation of the QOS of head and neck cancer patients, rehabilitation of the shoulder joint after neck dissection, management of radiation-associated dysphagia (RAD) by providing swallowing training, supportive care, early detection for minimally invasive surgery, and the de-escalation treatment strategy for Human Papilloma Virus-related oropharyngeal cancers. We must pay attention to offering head and neck cancer patients not only simple cure, but a better cure.

Investigation of Longitudinal Dose-weighted FDG-Positron Emission Tomography Metabolic Imaging Biomarkers (PET MIBs) of Radiation-associated Dysphagia in OPC Cohort

Head and neck cancer radiotherapy (RT) is associated with injury to dysphagia/aspiration at risk structures (DARS) with subsequent radiation-associated dysphagia (RAD). We sought to characterize the kinetics of standardized uptake values (SUV) derived from routine pre- and post-RT FDG-PET in DARS. We further sought to examine correlations between our proposed PET MIBs and Dynamic Imaging Grade of Swallowing Toxicity (DIGEST), a validated CTCAE-compatible modified barium swallow (MBS) grading scale of pharyngeal-stage dysphagia, in a subgroup of patients with standardly acquired MBS. Data for patients with oropharyngeal cancer (OPC) treated with RT (2005-2016) with available pre- & post-RT PET-CT scans, and DICOM-RT data, were retrospectively collected after an IRB approval. Analyzed DARS included soft palate (SP), genioglossus (GG), mylogeniohyoid complex (MGH), superior, middle and inferior constrictor muscles (SPC, MPC, and IPC) as well as ipsilateral (ipsi) and contralateral (contra) anterior bellies of digastric (DA) muscles. After CT-CT deformable image co-registration using commercial software (Velocity AI), DARS were sub segmented into smaller subvolumes based on the dose they received in 5 Gy increments, i.e. 0-5 Gy, 5-10 Gy subvolumes, etc. Volumetric as well as median dose-weighted SUV (calculated as: SUV * Planned DARS dose) were extracted from these whole and sub DARS volumes pre- & post-RT then compared using in-house algorithm. A corollary analysis was then performed on a subset of patients with prospectively collected DIGEST scores at 3-6-month post-RT (DIGEST 3-6ms) using Kruskal-Wallis tests. 904 DARS of 113 RT-treated OPC patients, were sub segmented & analyzed. DIGEST 3-6ms was reported for 39 patients as: grade 0-1, i.e. No or mild dysphagia (59%) or grade 2-3, i.e. moderate/severe (41%). Volumes and SUVmedian increased significantly after RT (p<0.0001) for all muscular DARS, including SPC, MPC, IPC, both DA, GG, and MGH complex, unlike soft palate that showed a decline in SUVmedian post-RT (p<0.0001). A Spearman rank correlation test showed a rising magnitude of delta-changes with higher DARS Dmean (p<0.05), e.g. IPC volume; ρ = 0.2, contra DA SUVmedian; ρ = 0.2, and MGH complex SUVmedian; ρ = 0.27. There was an increased likelihood of more severe dysphagia among patients with higher mean planned RT dose for all DARS (except MGH complex), more advanced cancer stage, those who received induction chemotherapy or reported some degree of dysphagia at presentation (p<0.05). Using multiple logistic regression to model DIGEST 3-6ms, SP Dmean, post-RT SP volume, post-RT, IPC SUVmedian, along with induction chemotherapy could adequately predict RAD severity; AUC = 0.86 (95% CI: 0.6-0.94; p<0.022). We sought to quantify pre- and post-RT FDG-PET metrics of DARS. Longitudinal kinetics of PET-derived metrics manifest dose-dependent changes that can potentially serve as MIBs of RAD measures using DIGEST score.

The Effect of Radiation Dose to the Pharyngeal Constrictor Musculature on Weight Loss During Treatment and Feeding Tube Dependence in Head and Neck Cancer

Radiation-associated dysphagia (RAD) is a common toxicity of radiotherapy (RT) for head and neck cancer, reported by nearly 50 percent of patients. Severe dysphagia can lead to feeding tube dependence, which significantly impacts quality of life. Studies have suggested that reduced radiation dose to the pharyngeal constrictor musculature (PCM) using intensity-modulated RT (IMRT) is associated with improved swallowing outcomes by a variety of measures. We aimed to identify dose-volume parameters of radiation to the PCM that are associated with weight loss during RT and percutaneous endoscopic gastrostomy (PEG) dependence as clinical measures of severe RAD. From a single institutional database, 115 patients with newly diagnosed head and neck squamous cell carcinoma of the oral cavity, nasopharynx, oropharynx, hypopharynx and larynx who underwent definitive or postoperative IMRT between January 1, 2014 and December 31, 2017 were identified after exclusion of patients with T1-2 stage larynx cancer, less than 6 months of follow-up and locoregional recurrence at any time. PCM was contoured prospectively and mean dose < 60 Gy was used as the dose constraint when possible. PCM dose-volume parameters were retrospectively collected from IMRT plans and logistic regression was used to analyze these data relative to percent weight loss during RT and duration of PEG use. 57% of patients had surgery prior to RT, 63% received concurrent chemotherapy and 70% had planned RT to the bilateral neck. 57% had some degree of dysphagia prior to RT. PEG tubes were placed prior to, during or just after RT in 45% of patients. The mean and median time from RT to PEG removal were 8.9 and 6.5 months respectively (range 1.9 to 36.7 months). The median percent weight loss during RT was 9.3% (range -5.7 to 23%). Definitive RT, bilateral neck volumes and concurrent chemotherapy were associated with weight loss and prolonged PEG use on univariate analysis. On multivariate analysis, female gender and concurrent chemotherapy were independently associated with prolonged PEG use and age < 60 and normal swallowing prior to RT were independently associated with weight loss > 10%. When adjusting for these significant confounding factors, PCM mean dose, max dose and V50-60 were significantly associated with prolonged PEG use: Means of these individual parameters for PEG use > 6 months were 57 Gy, 72 Gy, 80% and 54% respectively versus 48 Gy, 65 Gy, 58% and 28% for PEG use < 6 months. PCM V40 was significantly associated with > 10% weight loss during RT, with mean V40 of 85% for weight loss > 10% and 70% for weight loss < 10%. In this institutional cohort, IMRT dose to the total PCM correlated with severe RAD. Aiming to keep an overall PCM mean dose < 48 Gy and max dose < 65 Gy during IMRT planning may help reduce prolonged PEG dependence, while a PCM V40 < 70% may be associated with reduced treatment related weight loss.

Changing paradigms in the treatment of residual/recurrent head and neck cancer: implications for dysphagia management.

Despite advances in head and neck cancer treatment provision, recurrence rates remain high with the added risk of successfully treated patients developing a second primary. We report on the management of dysphagia in the context of residual/recurrent or new disease in a preirradiated field and make suggestions for future research. There have been numerous developments in treatment options for people with residual/recurrent head and neck cancer. This is because of improved surgical interventions including microvascular reconstruction techniques and transoral robotic surgery. In the era of highly conformal radiotherapy techniques, such as intensity-modulated radiotherapy (IMRT), there may be opportunities for re-irradiation. These advancements are now increasingly employed in the context of locoregionally recurrent disease. With results being reported from an increasing number of clinical trials, systemic therapies, including treatment with immunotherapy, offer the potential for increased survival with less treatment-related toxicity. Dysphagia is recognized as a significant toxicity following radical surgical and radiation-based approaches, particularly when multimodal treatment is required. Increasingly, late radiation-associated dysphagia is gaining greater attention in the literature. Many patients presenting with residual and recurrent disease do so against a background of comorbidities as well as persistent and late treatment-related toxicity.

Precision toxicity correlates of tumor spatial proximity to organs at risk in cancer patients receiving intensity-modulated radiotherapy

PurposeUsing a 200 Head and Neck cancer (HNC) patient cohort, we employ patient similarity based on tumor location, volume, and proximity to organs at risk to predict radiation-associated dysphagia (RAD) in a new patient receiving intensity modulated radiation therapy (IMRT). Material and methodsAll patients were treated using curative-intent IMRT. Anatomical features were extracted from contrast-enhanced tomography scans acquired pre-treatment. Patient similarity was computed using a topological similarity measure, which allowed for the prediction of normal tissues’ mean doses. We performed feature selection and clustering, and used the resulting groups of patients to forecast RAD. We used Logistic Regression (LG) cross-validation to assess the potential toxicity risk of these groupings. ResultsOut of 200 patients, 34 patients were recorded as having RAD. Patient clusters were significantly correlated with RAD (p < .0001). The area under the receiver-operator curve (AUC) using pre-established, baseline features gave a predictive accuracy of 0.79, while the addition of our cluster labels improved accuracy to 0.84. ConclusionOur results show that spatial information available pre-treatment can be used to robustly identify groups of RAD high-risk patients. We identify feature sets that considerably improve toxicity risk prediction beyond what is possible using baseline features. Our results also suggest that similarity-based predicted mean doses to organs can be used as valid predictors of risk to organs.

Pharyngeal Swallowing Pressures in Patients with Radiation-Associated Dysphagia.

Dysphagia associated with radiotherapy for head and neck cancer is complex and can be difficult to treat. Videofluoroscopic swallow studies (VFSS) are the current gold-standard instrumented swallow assessment. High-resolution manometry (HRM) is an additional approach that provides objective measurements of swallowing-related pressures in the pharynx and esophagus. This can provide functional information on the pressure gradients underlying bolus propulsion, and is relevant for this patient population, where radiation-related fibrosis can lead to weakness and impaired pressure generation. The purpose of this preliminary study was to describe pharyngeal swallowing pressures in patients with radiation-associated dysphagia (RAD) and late radiation-associated dysphagia (LRAD) using HRM. RAD occurs during and immediately following treatment, whereas LRAD is a more recently described phenomenon in which the patient experiences an onset of dysphagia at least 5years post-treatment. We performed a retrospective analysis of pharyngeal swallowing pressures from 21 patients with RAD or LRAD and 21 healthy sex/age-matched controls. Patients with RAD or LRAD exhibited decreased swallowing pressure durations throughout the pharynx (p ≤ 0.002), as well as decreased hypopharynx maximum pressure (p = 0.003) and pharyngeal contractile integral ( p < 0.0001). Understanding how pharyngeal pressure generation is altered in patients with a history of radiotherapy can help clinicians form more precise treatment plans.

Effect of tongue‐strengthening exercises on tongue strength and swallowing‐related parameters in chronic radiation‐associated dysphagia

Radiation-associated dysphagia (RAD) is highly prevalent in head and neck cancer (HNC) patients, with insufficient tongue strength (TS) as a characteristic of this disabling complication. The effects of tongue-strengthening exercises (TSE) on TS, swallowing, and quality of life (QoL) have not been studied in this population. A prospective phase 2 study using an 8 weeks during TSE protocol was carried out in 15 patients with chronic RAD. Outcome parameters were maximal isometric pressure (MIP), TS during swallowing (Pswal), swallowing function, and QoL. All parameters were evaluated at baseline, after 4 and 8 weeks of training, and 4 weeks after the last training session. MIP increased significantly, without detraining effects. Pswal did not increase significantly, but relevant effect sizes were measured. Swallowing function ameliorated, but did not result in increased functional oral intake, self-reported outcome or QoL. TSE in patients with RAD results in increased strength and swallowing function.

Automatic registration of 2D MR cine images for swallowing motion estimation.

PurposeTo automate the estimation of swallowing motion from 2D MR cine images using deformable registration for future applications of personalized margin reduction in head and neck radiotherapy and outcome assessment of radiation-associated dysphagia.MethodsTwenty-one patients with serial 2D FSPGR-MR cine scans of the head and neck conducted through the course of definitive radiotherapy for oropharyngeal cancer. Included patients had at least one cine scan before, during, or after radiotherapy, with a total of 52 cine scans. Contours of 7 swallowing related regions-of-interest (ROIs), including pharyngeal constrictor, epiglottis, base of tongue, geniohyoid, hyoid, soft palate, and larynx, were manually delineated from consecutive frames of the cine scan covering at least one swallowing cycle. We applied a modified thin-plate-spline robust-point-matching algorithm to register the point sets of each ROI automatically over frames. The deformation vector fields from the registration were then used to estimate the motion during swallowing for each ROI. Registration errors were estimated by comparing the deformed contours with the manual contours.ResultsOn average 22 frames of each cine scan were contoured. The registration for one cine scan (7 ROIs over 22 frames) on average took roughly 22 minutes. A number of 8018 registrations were successfully batch processed without human interaction after the contours were drawn. The average registration error for all ROIs and all patients was 0.36 mm (range: 0.06 mm– 2.06 mm). Larynx had the average largest motion in superior direction of all structures under consideration (range: 0.0 mm– 58.7 mm). Geniohyoid had the smallest overall motion of all ROIs under consideration and the superior-inferior motion was larger than the anterior-posterior motion for all ROIs.ConclusionWe developed and validated a deformable registration framework to automate the estimation of swallowing motion from 2D MR cine scans.

Chronic radiation-associated dysphagia in oropharyngeal cancer survivors: Towards age-adjusted dose constraints for deglutitive muscles

ObjectivesWe sought to model chronic radiation-associated dysphagia (RAD) in patients given intensity-modulated radiation therapy (IMRT) for oropharyngeal squamous cell cancer (OPSCC) as a function of age and dose to non-target swallowing muscles. MethodsWe reviewed 300 patients with T1-T4 N0-3 M0 OPSCC given definitive IMRT with concurrent chemotherapy. Chronic RAD was defined as aspiration or stricture on videoflouroscopy/endoscopy, gastrostomy tube, or aspiration pneumonia at ≥12 months after IMRT. Doses to autosegmented regions of interest (ROIs; inferior, middle and superior constrictors, anterior and posterior digastrics, mylo/geniohyoid complex, intrinsic tongue, and gengioglossus) were obtained from DICOM-RT plans and dose-volume histograms. The probability of chronic RAD as a function of mean ROI dose, stratified by age (<50, 50–59, 60–69, or ≥70 years), was estimated with logistic probability models and subsequent unsupervised nonlinear curves. ResultsChronic RAD was observed in 34 patients (11%). Age was a significant correlate of chronic RAD, both independently and with dose for all muscle groups examined. Distinct muscle-specific dose–response profiles were observed as a function of age (e.g., 5% of patients in their 50 s [but 20% of those 70 + ] who received 60 Gy to the superior constrictor had chronic RAD). This effect was stable across all observed muscle ROIs, with a false discovery rate-corrected p < 0.05, for all dose/muscle/age models, suggesting that including age as a covariate improves modeling of chronic RAD. ConclusionsAge at treatment moderates the probability of chronic RAD after chemo-IMRT for OPSCC, with aging muscles showing lower dose thresholds. Uniform dose constraints may not predict toxicity in older patients.

Application of Manual Therapy for Dysphagia in Head and Neck Cancer Patients: A Preliminary National Survey of Treatment Trends and Adverse Events.

BackgroundRadiation-associated dysphagia is a common and debilitating consequence of treatment for head and neck cancer (HNC). Since commonly employed dysphagia therapy programs for HNC patients still lack authoritative efficacy, some speech-language pathologists (SLPs) have started employing manual therapy (MT) techniques in an attempt to prevent or rehabilitate dysphagia in this patient population. However, exceptionally little is known about the use of MT in this patient population.ObjectivesThe purpose of this study was to describe practice patterns as well as the rate, type, and severity of adverse events associated with SLP provision of MT to HNC patients.MethodsAn Internet-based questionnaire geared toward SLPs who practice MT was developed and sent to SLPs practicing in the United States, 3 times, through 3 national listservs (American Speech Language Hearing Association [ASHA] Special Interest Division 13, ASHA Special Interest Division 3, and University of Iowa Voiceserv), over the course of 4 weeks.ResultsOf the 255 respondents, 116 (45.5%) performed MT on HNC patients. Of these 116 SLPs, 27.6% provided proactive MT during radiation, 62.1% provided 1 to 2 sessions per week, and 94.8% prescribed a MT home program. The rate, type, and severity of reported adverse events were similar between HNC and non-HNC patients.ConclusionThis preliminary survey demonstrated that SLPs provide MT to HNC patients during and after cancer treatment, and that reported adverse events paralleled those experienced by noncancer patients. However, these results should be taken with caution, and a well-designed prospective study is needed to formally establish the safety and the preliminary efficacy of this novel clinical intervention.