This is an extract from a 2015 newsletter of a meeting at Domain Lodge. Swallowing issues do not go out of date.
Speaking today was head and neck surgeon Dr Bren Dorman from the ORL department. His talk was on swallowing issues and consisted of
videos as well as slides. The videos were of scoping procedures within the hospital clinic or the ward, showing swallowing tests and impediments to swallowing as well as some of the treatments offered.
Patients in the videos had had mostly glossectomies or laryngectomies.
Extent of swallowing problems
Swallowing problems (dysphagia) can be experienced by anyone, not just head and neck patients. However, the problems experienced by head and neck patients are significant. A 2007 study of people who had surgery, radiation or chemoradiation found that many patients struggled considerably four years
after treatment. 50.6% experienced dysphagia, more patients (72.4 %) struggled with solid food. 57.1% needed nutritional support while 20.3% developed malnutrition.
What swallowing involves
Swallowing includes more than we think. It involves oral preparation of the food in the mouth plus manipulating and positioning it with the tongue. Saliva is needed. (In my case I can swallow liquids easily but solid food gets stuck in my mouth so technically I have a swallowing problem.)
I found this quotation on an SLT site that helped me understand what Dr Dorman said about the importance of the larynx and vocal folds to swallowing.
Swallowing is a complex and coordinated activity that requires various muscle groups and other structures, including the larynx, to function in a swift and coordinated manner. When this doesn’t happen, often this can result in food or liquid falling into the trachea, known as “aspiration.” This is what happens when a person chokes.
Food has to go down the food pipe (the oesophagus) not the windpipe (the trachea) but if the normal safeguards are not working, food can go down the wrong way. The epiglottis, which acts as a sort of trapdoor, is important for this as are the vocal folds of the larynx and the upper oesophageal sphincter.
Loss of organs like the tongue and the larynx can cause swallowing problems. Flaps are great but they might not move and could therefore make swallowing difficult. Initially the flap is quite swollen and may take weeks to months to shrink. The loss of functioning salivary glands through surgery or radiation also has a big effect. Radiotherapy can “cook” salivary glands, which will affect ongoing production of salivary secretions.
Effect of radiation on swallowing
Radiation treatment has many side effects which hinder swallowing. Some are:
* Pain or odynophagia
* Trismus: difficulty with mouth opening
* Thick secretions
* Oesophageal stricture and stenosis (scarring)
Surgical treatments like any tongue or mouth surgery can have an effect on preparing food in the mouth.
Swallowing Tests and Treatments
Endoscopic examination is that lovely procedure where you have a camera on a flexible tube poked up your nose and down your throat. You can also get a Functional Endoscopic Evaluation of Swallowing or FEES which is easily done by the SLT in the clinic.
Balloon dilation can also be done this way. If the oesophagus is narrowed by scarring, it can be dilated with a syringe driven expander opening the oesophagus by splitting scars. This procedure can be performed in the clinic under a local anaesthetic or in surgery under a general anaesthetic.
Dr Dorman also showed us a video of a modified barium swallow using a special movie-type x-ray. The patient had had a total glossectomy. They were looking to see if fluid went down the oesophagus or was aspirated.
He showed a FEES procedure where the patient had to swallow blue-dyed pear puree to see if it went down the right way. If there’s a suspected nerve problem the doctor can poke the area with the camera to test for sensation. This process should stimulate a cough
The patient is told to do a safe swallow, for example, “Look at the right armpit” if there is a problem to the right side.
With larynx cancer a little valve can be put in with a scalpel via endoscopy. Some solutions can be carried out in the clinic with a local. Some patients can tolerate this and some need general anaesthesia. There is no right and wrong.
One video showed that one of the vocal folds didn’t close properly. They need to close for successful swallowing.
Questions and Answers
How to deal with a dry mouth
You can stimulate any remaining salivary glands with something like citrus, although as Esther pointed out this can be damaging to the teeth. To deal with dryness itself any oil will help if placed in the mouth. Esther mentioned rice bran or flax seed oil. If you don’t like oil then you can use butter or margarine.
Pilocarpine is a saliva-increasing drug but it hasn’t been successful because of side effects.
Chewing gum and lozenges help. It’s the movement that helps the saliva. Bantu in the Kalahari Desert used to suck a stone in the mouth, while one patient found that tiny bits of carrot held in the mouth helped her keep her mouth moist. Coffee and strong teas cause dryness.