ORIGINAL ARTICLELong-term prevalence of oropharyngeal dysphagia in head and neck cancer patients: Impact on quality of life☆
Introduction
Head and neck cancer (HNC) refers to tumors of the oral cavity, pharynx, and larynx.1 The prevalence of such tumors is high and has increased in recent decades. Among the risk factors related to these cancers are alcohol and tobacco use.2 The prevalence of HNC in the Spanish population is approximately 35/105.3 The mortality associated with these tumors is approximately 10%,4 and high morbidity is associated with treatment.
These patients present oropharyngeal dysphagia.5 This symptom refers to difficulty swallowing, from the mouth to the esophagus. Its severity may vary from moderate difficulty swallowing to impossibility of oral feeding.6 Its etiology is multifactorial due to the consequences of surgery and coadjuvant treatment (mucositis, xerostomia, dysgeusia, odynophagia, etc.).7, 8, 9 In many patients, dysphagia may persist for years after treatment.10, 11
Oropharyngeal dysphagia can cause two types of severe complications for the patient. The first is development of malnutrition and dehydration.12 The second is increased risk of aspiration. It is known that aspiration pneumonia occurs in up to 50% of patients with dysphagia, with a 50% mortality rate.13
Malnutrition may decrease the strength of the muscles involved in the swallowing process.14 In addition, dehydration may increase mucosal dryness and decrease salivation. Furthermore, both may negatively affect quality of life (QoL)15 and increase morbidity/mortality.16
So, it is necessary that these patients have undergo nutritional surveillance throughout their treatment.17, 18
We studied the prevalence of oropharyngeal dysphagia in a series of HNC patients who had been treated with surgery, radiotherapy, and chemotherapy, and its influence on nutritional status and QoL.
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Materials and methods
This is a retrospective cross-sectional study. Medical records database was used to search HNC patients operated on by Maxillofacial Surgery Service from January 2000 through May 2005. Patients were phoned at home from June 2005 to October 2005 and were invited to participate in the study. Patients were interviewed by a trained person and dysphagia, nutritional status and QoL were evaluated.
Eighty-seven out of 97 HNC patients could be contacted (61 males, 26 females) with a mean age of
Dysphagia
The prevalence of dysphagia in these patients was 50.6%. Depending on food consistency, dysphagia to solid food was present in 72.4% of patients, to semisolid food in 17.2%, and to liquid food in 17.2%. Nearly 34% of patients had to swallow more than once to pass the entire bolus. Edentulism was present in 36.8% of patients, xerostomia in 18.4%, and odynophagia in 11.5%.
The prevalence of dysphagia as a function of surgery and coadjuvant treatment is shown in Figure 2. Patients treated with
Discussion
The diagnosis of oropharyngeal dysphagia may be based on clinical or radiological methods. Clinical methods include specific tests to detect dysphagia19 and clinical evaluation of deglutition by administering boluses of different volumes (3–20 ml) and viscosities (liquid, nectar, and pudding).5 Radiological methods, which include videofluoroscopy and pharyngoesophageal manometry,5 appear to be the methods of choice.
In our study, we chose a clinical test to detect dysphagia because we consider it
Limitations of the study
The major limitations of the study are due to the retrospective condition of the study. Some epidemiological data could contain some mistakes due to their collection were retrospectively. We could not contact some patients, probably because they had died, and this could produce some biases. The coadjuvant treatment depending on stage of tumor could produce biases in the statistical analysis of the other variables as dysphagia, malnutrition or QoL.
Conclusions
HNC patients treated with surgery, radiotherapy, and chemoradiotherapy develop oropharyngeal dysphagia.
Dysphagia significantly affects their QoL.
Patients with total glossectomy treated with chemoradiotherapy in their first year after surgery presented the highest prevalence of dysphagia and the worst QoL.
Dysphagia did not significantly affect nutritional status, probably because these patients developed adaptive eating mechanisms.
It is necessary to perform a clinical test to detect dysphagia,
Conflict of interest statement
None declared.
Acknowledgments
This study was supported by a research grant from Novartis Medical Nutrition. PG designed the study, carried out the data analyses and drafted the manuscript. LP carried out the study and the data analysis. CV participated in the carried out of the study and performed the statistical analysis. CC participated in its design and helped to draft the manuscript. MC and IB participated in the design of the study. HH, JV, and CN were the patients’ surgeons and participated in the design of the study.
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Parts of these data were presented as a poster in Clinical Nutrition Week 2007 (ASPEN). Phoenix, Arizona, USA. January 2007.